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Tibial shaft (diaphyseal) fracture - Fracture clinics
Treatment is supportive. A backslab can be applied. An above-knee walking cast for 4 weeks is optional
Fracture clinic in 2 weeks with x-ray
Undisplaced tibial shaft fracture
No reduction is needed. Above-knee cast for 4-6 weeks (age and healing-dependent)
Patient would benefit from procedural sedation for application of the cast
Fracture clinic in 1 week with x-ray
Displaced tibial shaft fracture + / - fibular shaft fracture
See acceptable reduction parameters
Closed reduction with above-knee cast for 4-6 weeks (age and healing-dependent), non-weight bearing
Unstable fractures may require general anaesthesic, manipulation and plaster GAMP) or fixation in theatre
Tibial shaft (diaphyseal) fractures can be classified by:
Tibial shaft fractures are the third most common long bone fracture in children and adolescents.
Fractures of the shaft of the tibia can result from a direct blow or a rotational force. Direct trauma frequently produces a transverse fracture or segmental fracture pattern, whereas rotational forces typically result in an oblique or spiral fracture.
Thirty percent of tibial shaft fractures are associated with a fibula fracture
The child will present with pain, swelling and/or deformity in the lower leg. The child will not want to weight bear on the injured leg.
Toddler fractures occur in young ambulatory children (from 9 months to 3 years). A toddler's fracture is a spiral or oblique undisplaced fracture of the distal shaft of the tibia with an intact fibula. The periosteum remains intact and the bone is stable. These fractures occur as a result of a twisting injury. Septic arthritis and osteomyelitis should be excluded.
Anteroposterior (AP) and lateral x-rays of the tibia and fibula to include knee and ankle joints should be ordered.
Figure 1: Toddler fractures are often radiographically normal on initial x-ray. A) AP and lateral x-ray of a 15 month old boy who refused to weight bear. No fracture can be seen. When routine radiographs are normal but a fracture is suspected, oblique views may help visualise the fracture line. B)Radiographic evidence may only become apparent 7-10 days after the initial injury when new periosteal bone formation occurs (white arrow).
Figure 2: Undisplaced complete isolated fracture of the tibial shaft. Most tibial shaft fractures are short oblique or transverse fractures of the middle or distal third.
Figure 3: With an intact fibula it will tend to push the tibia into varus during healing. Thus when casting this fracture the cast should be moulded into slight valgus to protect against this.
Figure 4: AP and lateral x-ray of tibia and fibula shaft. The tibial shaft fracture is located in the distal third. The fibula fracture is located in the proximal third.
Reduction is required with any displaced fracture. The majority will require closed reduction.
AP and lateral radiographs of the tibia, including the knee and ankle joints should be obtained immediately after reduction to verify alignment.
Table 1: Acceptable reduction parameters.
AP or lateral x-ray
Indications for prompt consultation include:
Type of reduction
Immobilisation method and duration
No reduction is needed
No reduction is needed, however the patient would benefit from procedural sedation for application of the cast
Above-knee cast for 4-6 weeks (age-and healing-dependent), non-weight bearing. Above-knee cast should typically have the knee flexed to 30-40 degrees and the ankle in neutral dorsiflexion
Change to patellar tendon-bearing/below-knee cast
Patella tendon-bearing cast
Unstable fractures may require general anaesthetic, manipulation and plaster (GAMP) or fixation in theatre
Patients who have undergone a closed reduction and casting need follow-up in 1 week in the fracture clinic with an x-ray.
Most fractures will heal well without complication in 8-12 weeks. Close follow-up is important to monitor fracture alignment.
Parents and the child should be given education on cast care. Give "Caring for your child in a leg cast" fact sheet.
13. What are the potential complications associated with this injury?
See fracture clinics for other potential complications.
Halsey MF, Finzel KC, Carrion WV, Haralabatos SS, et al. Toddler's fracture: presumptive diagnosis and treatment. J Pediat Ortho 2001; 21(2): 152-6.
Price CT, Flynn JM. Management of fractures. In Lovell and Winter's Pediatric Orthopaedics, 6th Ed, Vol 2. Morrissy RT, Weinstein SL (Eds). Lippincott, Philadelphia 2006. p.1430-521.
Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. J Am Acad Ortho Surg 2005; 13(5): 345-52.
Henrich SD, Mooney JF. Fractures of the shaft of the tibia and fibula. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.930-66.
Yang JP, Letts RM. Isolated fractures of the tibia with intact fibula in children: a review of 95 patients. J Pediat Ortho 1997; 17(3): 347-51.