Fractures of the Tibia and Fibula
in the Pediatric Patient
Steven Frick, MD
Created March 2004; Revised August 2006
Growth and Development of the
Tibia and Fibula
• More growth proximally than distally in
both
• Fibula moves distally relative to the tibia
with growth
• Extraphyseal fractures rarely disturb future
growth and development (exceptions=
proximal tibia, crossunion)
Relevant Anatomy
• Tibia and fibula bound together by
interosseous membrane
• Some motion occurs normally (proximal
distal translation, inward/outward rotation)
at proximal and distal tibiafibular joints
• Subcutaneous location of tibia- implications
for susceptibility to injury and healing
potential
Incidence
• Low energy fractures
common (toddler’s
fracture, spiral tibia
fractures)
• Of open fractures in
children, tibia is most
frequent location
Physical Examination
• Integrity of the skin and severity of soft
tissue injury
• Dorsalis pedis and posterior tibialis pulsers,
distal capillary refill
• Peroneal and posterior tibial nerve function
• Any signs of compartment syndrome
Compartment Syndrome
• Can occur in skeletally immature patient after
closed or open tibia fracture
• Tense compartment, pain out of proportion, pain
with passive stretch, paresthesias in distribution of
nerves that are in compartment
• Compartment pressure measurement to confirm
• Consider conscious sedation / general anesthesia
in child to measure pressures
• Fasciotomies emergently if diagnosed
Radiographic Evaluation
• 2 Orthogonal views usually adequate
• Visualize knee and ankle joints
• Assess for
displacement/displacement/translation,
shortening, angulation
• Rotation best assessed clinically
Classification
• Open/Closed
• Tibia, Fibula or both
• Fracture location- proximal or distal,
metaphyseal or diaphyseal
• Fracture pattern- transverse, spiral,
butterfly, comminuted
Decision Making-Principles for
Treatment
• Restore acceptable length, alignment, translation
and rotation
• What is acceptable? Little hard date available,
depends on age of patient
• General guidelines for acceptable position: <10°
angulation, <2cm shortening, <50% translation,
rotation equal to opposite side
• Fractures that heal in positions outside these
guidelines may remodel or go on to good clinical
result
Principles of Treatment
• Majority of tibia/fibula fractures in children
can be treated closed
• Careful attention to casting technique
• Radiographic monitoring at regular
intervals during early healing- wedge cast,
or remanipulate/recast for unacceptable
reduction/position
Treatment Options
• Cast above knee usually, but below knee acceptable for
stable fracture patterns or after early healing
• Pin fixation and cast- simple and effective, especially in
oblique fractures, younger children
• External fixation- high energy fractures with associated
soft tissue injuries
• Flexible nails- proximal medial and lateral insertion
• Rigid nail- if near skeletal maturity
• Plate fixation- if soft tissues allow
Specific Fractures
•
•
•
•
•
•
•
Toddlers
Proximal tibia metaphyseal fracture
Isolated fibula fracture
Isolated tibia fracture- mid/distal third
Open tibia
Distal metaphyseal tibia
Floating knee
Toddler’s Fracture
• Very common in
young children
• Accidental
• Stable
• Above knee cast with
knee flexed 10 degrees
for three weeks
Proximal Tibia Metaphyseal
Fracture
• Potential for valgus overgrowth
• Usually 3-6 years old when femoral- tibial
angle growing towards valgus
• Varus mold may prevent
• Some believe in completing the fracture
• Valgus can be severe but usually remodels
over years such that corrective osteotomy
unnecessary
Valgus after Proximal Tibia
Metaphyseal Fracture
Asymmetric growth
slowdown lines
Persistent bow
Valgus following
Proximal Tibia Fracture
Case courtesy of K. Shea. Observe and often improve with
time, but may need guided growth surgical intervention
Isolated Fibula Fractures
• Direct blow mechanism
• Immobilize as needed for comfort(fibula
15% of weight bearing)
• Carefully assess ankle (r/o Maissenouve
injury)
Indications for Surgical
Treatment
• Inability to obtain/maintain acceptable
position
• Open fractures
• Multiple trauma to facilitate mobilization
Isolated Tibia Fracture with
Intact Fibula
• Often at middle/distal
third
• Muscle
forces/biomechanics
usually result in drift into
varus angulation
• Valgus mold in initial cast
• Can wedge at 2 weeks but
more difficult because of
intact fibula
Open Tibia Fractures
• Soft tissue injuries typically less severe than in
adults
• Periosteum often intact on concavity
• Appropriate debridement, antibiotics
• Pins and cast, external fixation, flexible
intramedullary rods all useful – choice depends on
age, fracture pattern, status of soft tissues,
associated injuries
• Lower malunion rates and best outcomes seem to
be reported after flexible nailing
Open Tibia Fracture with
Soft Tissue Deficits
Appropriate pin placement
and construct needed to
control varus
Open Tibia FracturesI&D, Flexible Nailing
Distal Metaphyseal Tibia
Fracture
• “Gillespie” fracture – apex posterior
angulation distal tibia
• Dorsiflexion of ankle to neutral may
increase apex posterior angulation
• Cast in equinus until early healing, then
change cast and dorsiflex to neutral
Gillespie Fracture – Healed in
Excessive DF as was Casted with
Ankle at Neutral
Pinning and Cast after Failure to
Achieve Acceptable Alignment with
Closed Methods
Floating Knee Injuries
• Ipsilateral femur and tibia fractures
• Typically high energy mechanism
• Operative stabilization of at least one of
fractures recommended
• Often may treat femur operatively and tibia
nonoperatively
• If both displaced / unstable recommend
fixation of both
12 Year Old, Pedestrian vs. Car
Floating Knee
Healed Floating Knee
Expected Outcomes
• Usually heal in 6-12 weeks in
juveniles/adolescents
• Nonunions rare
• Malunion- no accepted definition, later
adverse of malunion poorly documented
• Remodeling potential- especially for
metaphyseal fractures in younger patients
Tibia Fracture Malunion/Nonunion
Varus – procurvatum malunion following premature
removal of ex fix after open tibia fracture
Isolated Tibia Fracture Casted with Valgus
Mold – Healed with Excellent Alignment
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