Proximal tibial fractures in children

INTRODUCTION — The evaluation and management of proximal tibial fractures in children is reviewed here. Other pediatric fractures of the tibia or fibula are discussed separately. (See "Tibial and fibular shaft fractures in children" and "Stress fractures of the tibia and fibula" and "Ankle fractures in children".)

EPIDEMIOLOGY — Proximal tibial fractures are infrequent in children relative to diaphyseal and distal tibial fractures. In toddlers, metaphyseal corner or bucket handle fractures are highly associated with child abuse. (See "Orthopedic aspects of child abuse".)

Other patterns of injury correspond to the age of the child and the type of force [1]:

●Young children (three to nine years of age) are at risk for greenstick or complete metaphyseal fractures when valgus or varus stress is applied. Jumping on a trampoline with other children is a common mechanism.

●Older children (10 to 12 years of age) are at risk for tibial spine avulsion from hyperextension and rotation injury (eg, most commonly a fall from a bicycle or motorbike).

●Physeal fractures are commonly seen in young adolescents (12 to 14 years of age) and are related to high energy mechanisms (eg, sports injuries, motor vehicle collisions) (figure 1). These fractures are significantly more common in males than females [2].

●Tibial tubercle avulsion occurs in older adolescents during active quadriceps contraction with forced flexion of the knee (eg, landing from a jump during basketball, hurdling, high jump or gymnastics or being tackled in American football or rugby).

CLINICAL ANATOMY — The tibia is the major weight-bearing bone of the lower leg (figure 2 and figure 3). The proximal portion of the bone, the tibial plateau, forms the lower surface of the knee joint (figure 4). The thicker of the two articular surfaces is the medial tibial condyle, while the lateral tibial condyle is a relatively thinner and weaker portion of the joint. Separating the medial from the lateral tibial condyle is the tibial spine (intercondylar eminence), an important bony prominence that anchors the attachment of the anterior cruciate ligament (ACL).

The diaphysis, or long shaft of the bone, flares at either end of the bone metaphysis and terminates in the rounded end of the bone called the epiphysis. The physis, or growth plate, is the active zone of bone lengthening that links the epiphysis to the rest of the bone (figure 5). The epiphysis of the proximal tibia is a pressure epiphysis and is subject to compressive forces. Injuries to pressure epiphyses and to growth plates can result in growth disturbances.

The tibial tuberosity is another key landmark located on the anterior surface, one to two centimeters below the joint line and the inferior patellar pole [3]. As the site of attachment for the patellar tendon, the tubercle is subject to tensile forces and thus, both inflammatory and avulsion injuries. However, injury to the tubercle does not pose a risk of growth disturbance.

The interosseous membrane is a strong fibrous structure that connects the tibia and fibula along the length of the two bones. Proximally, this structure, reinforced by strong anterior and posterior ligaments, forms a synovial joint, the proximal tibiofibular articulation.

Another fibrous structure, the crural fascia, surrounds the bones and muscles of the lower leg. Fascial extensions and the interosseous membrane separate the muscles, nerves, and vessels of the lower leg into four distinct compartments (figure 6). Three of these, the anterior, posterior, and deep posterior compartments, all border the tibia and can be compromised by tibial injury.

Vascular compromise can arise more proximally from the following etiologies [4]:

●Marked knee effusion

●Popliteal artery injury before it branches into the anterior and posterior tibial arteries

●Anterior tibial artery as it branches off the popliteal artery and passes through a gap in the interosseous membrane

The tibial and common peroneal nerves and their branches provide the key innervation to the muscles of the lower leg and foot. The tibial nerve parallels the course of the posterior tibial artery and courses through the deep posterior compartment. In the popliteal space, branches of the tibial nerve provide innervation to the posterior compartment and to the popliteus muscle. The common peroneal nerve divides to form the superficial and deep peroneal nerves, providing innervation to the muscles in the lateral and anterior lower leg, respectively.

MECHANISM OF INJURY — Different mechanisms account for the different types of proximal tibial fractures seen in children [5]:

●Metaphyseal fractures – Two types of mechanisms are associated with these injuries:

•Metaphyseal corner or bucket handle fractures result from intentional pulling and rotation forces applied to the leg when a toddler is grabbed by the ankle or by rapid acceleration and deceleration forces, such as when an infant is shaken violently while the legs are dangling.

•Metaphyseal greenstick or complete fractures occur from medial (varus stress) or lateral (valgus stress) forces applied to the lower leg, such as from a child going down a slide on a parent/caregiver's lap with an outstretched leg.

●Proximal tibial physeal fractures – These fractures are most common in young adolescent patients who sustain high energy trauma during sports or motor vehicle collisions.

●Tibial spine fractures – This fracture results from a hyperextension of the knee with concurrent rotation of the femur on the tibia. It is the same mechanism as an ACL injury in older patients and patients may have concomitant ACL injuries [6].

●Tibial tubercle avulsion fractures – These injuries typically occur during forced flexion against actively contracting quadriceps (eg, an adolescent planting a leg to dunk a basketball) (figure 7).

Repeated flexion of the knee occurs in athletes who kick and jump or who climb steps for training. These activities engage the quadriceps muscles and exert force on the patellar tendon and its insertion site, the tibial tubercle. This repeated pulling on the tubercle in young adolescents may lead to an apophysitis (Osgood-Schlatter disease). (See "Osgood-Schlatter disease (tibial tuberosity avulsion)".)

PHYSICAL FINDINGS — The physical examination of children with suspected tibial fractures is described in greater detail separately. (See "Overview of tibial fractures in children", section on 'Examination'.)

Children with proximal tibial fractures often have pain, swelling, and/or deformity at the site of injury. These patients usually are unable to walk.

Additional findings of specific fractures are as follows:

●Transverse proximal physeal tibial fractures – Patients often demonstrate hemarthrosis and tenderness at the knee joint and are unable to lift the leg due to pain and large muscle spasm. Rarely, posterior displacement of the fracture may cause injury to the popliteal artery (figure 8). In such patients, distal pulses or perfusion of the foot are typically diminished and ischemia may be present. (See 'Vascular compromise' below.)

Hyperextension of the knee during the exam should also be avoided to prevent vascular compromise [7]. These fractures are associated with ipsilateral femoral and/or tibial shaft fractures [8].

●Metaphyseal fractures – The toddler with a corner or bucket handle fracture typically limps or refuses to bear weight, but the exam may otherwise not reveal any localized swelling or deformity. Other findings of physical abuse may be present. (See "Physical child abuse: Recognition", section on 'Red flag physical findings'.)

●Greenstick or complete fractures – Older children with greenstick or complete fractures typically have severe pain and swelling at the fracture site. Deformity may also be evident. Posterior displacement of the fracture may impinge upon the popliteal artery or anterior tibial artery and cause distal vascular compromise.

●Tibial spine fractures – These children will have a hemarthrosis, knee joint tenderness, and a markedly decreased range of motion.

●Tibial tubercle avulsions – Patients are unable to move the knee and have proximal displacement of the patella with bunching and spasm of the quadriceps muscles.

RADIOGRAPHIC FINDINGS — Anterior-posterior (AP) and lateral plain radiographic views of the lower leg, including the knee and ankle, should be obtained in the child with a suspected proximal tibial fracture to establish the diagnosis.

Proximal tibial physeal fractures are classified using the Salter-Harris system (figure 1). Complicated fractures may require additional imaging (eg, computed tomography, magnetic resonance imaging [MRI]) in consultation with a radiologist or orthopedic surgeon to fully characterize the injury. In addition, fractures that are irreducible may have entrapped periosteum that is best visualized by MRI [9].

Toddlers with abusive tibial metaphyseal injuries may have a small triangle of avulsed bone (the "corner fracture") or may show the C-shape of a bucket handle if the x-ray beam is directed obliquely to capture the sub-periosteal layer that is pulled away from the bone (figure 9). (See "Orthopedic aspects of child abuse", section on 'Location and type of fracture'.)

Patients with avulsion of the tibial tubercle have a fracture through the base of the tubercle with proximal displacement of the fragment which remains attached to the patellar tendon.

INITIAL MANAGEMENT — The patient with a suspected tibial fracture should undergo evaluation and management appropriate to the patient's mechanism of injury and physical findings. The clinician should evaluate unstable patients and those with a high risk trauma mechanism (table 1) according to the principles of advanced trauma life support (ATLS) (table 2). (See "Trauma management: Approach to the unstable child" and "Approach to the initially stable child with blunt or penetrating injury".)

In patients with closed proximal tibial fractures and no sign of neurovascular compromise, initial management focuses on pain control, immobilization of the fracture, and reduction of swelling. (See "Overview of tibial fractures in children", section on 'Initial management'.)

Vascular compromise — Proximal tibial fractures may rarely cause vascular compromise if accompanied by marked effusion of the knee joint and/or posterior fracture displacement with impingement of the popliteal or anterior tibial artery (figure 3). In these children, distal pulses and perfusion are diminished and severe ischemic pain is often present.

The emergency clinician should promptly identify children with vascular insufficiency and obtain emergency consultation from an orthopedic surgeon with appropriate pediatric expertise. Rarely, these children will require partial closed reduction in the emergency department to restore distal circulation. Patients who display a cold, white, or cyanotic foot despite fracture reduction require operative exploration and vascular repair.

Open fractures — In addition to pain management and immobilization, children with an open proximal tibial fracture should receive antibiotics and tetanus prophylaxis (table 3). (See "General principles of fracture management: Early and late complications", section on 'Open fractures'.)

The choice of prophylactic antibiotics depends upon the type of open fracture and is derived from evidence in adults as discussed separately. (See "Osteomyelitis associated with open fractures in adults", section on 'Antibiotics after open fracture'.)

Open fractures of the proximal tibia warrant prompt orthopedic consultation for potential operative debridement and repair.

Patients with type I open fractures of the tibia (ie, clean wound <1 cm in length) usually have minimal soft tissue injury and intact local perfusion. These fractures have low infection rates (table 4). Preliminary evidence from a case series of 40 children (mean age 8.6 years) suggests that nonoperative treatment of these injuries with irrigation, one dose of intravenous antibiotics, and casting in the emergency department can have good results [10]. However, given the limited numbers of patients in this series, further study is needed before nonoperative treatment of these injuries becomes routine. An orthopedic consultation should always be obtained for these patients.

Predebridement wound cultures do not correlate with infectious pathogens in patients with open fractures and are not recommended.

Acute compartment syndrome — Compartment syndrome may rarely occur prior to or after definitive orthopedic care of a proximal tibial fracture. When compartment syndrome is suspected based on clinical findings, immediate management includes relieving all external pressure on the compartment. Any dressing, splint, cast, or other restrictive covering should be removed. The limb should NOT be elevated. Elevation can diminish arterial inflow and exacerbate ischemia.

Suspected compartment syndrome should prompt emergent orthopedic consultation. Compartment pressure measurement helps identify patients in need of fasciotomy, the definitive treatment for decompression of all involved compartments. (See "Acute compartment syndrome of the extremities", section on 'Measurement of compartment pressures' and "Acute compartment syndrome of the extremities", section on 'Management'.)

Child protection — Diagnosis of a metaphyseal fracture (corner or bucket handle fracture) in a toddler is highly suggestive of child abuse and should prompt involvement of an experienced child protection team (eg, social worker, nurse, child abuse specialist). In many parts of the world (including the US, UK, and Australia), a mandatory report to appropriate governmental authorities is also required for cases of suspected abuse. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

Children with suspected intentional trauma based on concerning injury patterns (eg, corner or bucket handle fracture) warrant further evaluation guided by a child abuse specialist. These measures should be performed after the patient's clinical status is stabilized. The safety of other children in the home must be ensured by local Child Protective Services. (See "Physical child abuse: Diagnostic evaluation and management".)

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — Prompt orthopedic consultation should be obtained in patients with any of the following proximal tibial fractures [11]:

●Fractures complicated by neurovascular compromise or acute compartment syndrome

●Open fractures

●Metaphyseal fractures

●Displaced physeal fractures

●Fracture with intra-articular extension

●Displaced tibial tubercle avulsion

Children with complete tibial tubercle avulsions or tibial spine fractures may be treated initially with a knee immobilizer and made non-weight bearing. They should have early orthopedic follow-up within one week.

DEFINITIVE CARE — The care of proximal tibial fractures in children is guided by case series and empirical observation and varies depending on the type of fracture:

Physeal fractures — Treatment varies by the severity of the fracture and degree of displacement (figure 1):

●Nondisplaced Salter-Harris I or II fractures may be splinted in mild flexion. Given the higher risk for vascular injury, close orthopedic follow-up of the child is warranted. Orthopedic care typically consists of a long leg cast with the knee in mild flexion for four to six weeks with frequent orthopedic visits for assessment of bone healing and cast integrity.

●Displaced Salter-Harris I or II fractures warrant prompt orthopedic consultation for closed reduction. Once reduced, the child is typically placed in a long leg cast with the knee in mild flexion for six weeks with frequent orthopedic visits for assessment of bone healing and cast integrity.

●Salter-Harris III or IV fractures warrant prompt orthopedic consultation for closed or open reduction with internal or external fixation. Patients who require fixation are immobilized in a long leg cast until two to three weeks after hardware removal as long as adequate bone healing is present. Patients not requiring fixation are typically casted for six weeks or until adequate bone healing has occurred based on frequent orthopedic follow-up.

●Salter-Harris V fractures cause a total or partial erasure of the growth plate and are very rare in the proximal tibia. When recognized, they warrant long-term orthopedic follow-up for the expected growth arrest with shortening of the affected extremity.

Generally, all physeal fractures require long-term orthopedic follow-up to monitor for growth arrest.

Metaphyseal fractures — Metaphyseal fractures warrant prompt orthopedic consultation. Orthopedic treatment of proximal tibial metaphyseal fractures is dictated by the mechanism of injury. Typical low energy mechanisms occur in younger children, age three to six, and manifest as buckle or incomplete fractures through the proximal tibial and fibular metaphyses. These are routinely managed with closed reduction and casting.

High energy mechanisms cause complete transverse fractures with displacement and are usually found in an adolescent age group. These often require surgical stabilization and careful, repeated evaluation to exclude the possibility of vascular injury or compartment syndrome.

If closed reduction and long leg casting with the knee in extension are performed, radiographs of both tibias should be taken to ensure that the injured tibia is adequately aligned.

Toddlers with metaphyseal corner or bucket handle fractures are treated in a long leg cast with the knee in extension. These patients warrant additional evaluation for child abuse. (See 'Child protection' above.)

Tibial spine avulsion — Initial treatment typically consists of immobilization. Some experts recommend splinting in full extension or hyperextension [12]. The patient should be made non-weightbearing on the affected extremity and given crutches.

Significantly displaced anterior tibial spine avulsions require referral for closed or open reduction with internal fixation [13,14].

Non-displaced fractures can be treated in a cast and heal in approximately six weeks [14]. Radiographs of the casted fracture should be repeated after two weeks and again at the time of cast removal to confirm adequate bone healing. Adolescents typically recover motion rapidly following cast removal. Most younger patients will regain strength and return to sports four weeks after cast removal if they receive proper rehabilitation.

Tibial tubercle avulsion — Treatment of avulsions varies by the degree of displacement and the size of the fragment:

●Fractures with displacement or intra-articular extension merit prompt consultation or referral to assess the need for operative intervention (image 1).

●Minimally displaced tibial tubercle avulsions can be treated initially with a knee immobilizer and subsequently transitioned to a long leg cast in follow-up.

Initial therapy for nondisplaced tibial tubercle avulsion typically consists of an appropriate length knee immobilizer. The patient should be made non-weight bearing on the affected extremity and given crutches.

Adolescents heal rapidly and begin rehabilitation and moderate activity after coming out of immobilization. Assessment of quadriceps strength should show a steady gain. Patients should be advised against jumping or returning to full sports activity until they have regained 80 to 90 percent of the quadriceps strength of the unaffected side.

DISCHARGE AND FOLLOW-UP — Following definitive care, children with proximal tibial fractures should follow up with an orthopedic surgeon. Timing depends on the type of fracture and treatment provided:

●Nondisplaced physeal fractures – One week

●Metaphyseal fractures – One week

●Tibial spine fracture – Two to three days

●Complete tibial tubercle avulsion – Two to three days

All patients should be provided with crutches and instructed to remain nonambulatory. They should also keep the fracture site elevated above the level of the heart as much as possible for the first 48 hours after injury.

Children who receive a cast and their caretakers should be given detailed cast care instructions. (See "Patient education: Cast and splint care (Beyond the Basics)".)

Home pain management — Proximal tibial injuries are often very painful. Most clinicians choose to provide a prescription for a limited amount of opioid pain medication (eg, oxycodone). In some cases (eg, children with nondisplaced metaphyseal fractures or Salter-Harris I fractures and minimal pain), opioid medications are not necessary.

COMPLICATIONS — The most common complications of proximal tibial fractures in children are as follows:

●Valgus deformity – Fractures of the proximal tibial metaphysis are prone to develop a progressive valgus angular deformity, despite anatomic alignment during the initial treatment. This may reflect altered growth mechanics about the proximal tibial physis. The vast majority of the progressive valgus will resolve spontaneously over three years. However, close orthopedic follow-up is needed for those few cases where osteotomy may be necessary to correct the angulation if it does not resolve.

●Popliteal artery injury – With a significant hyperextension injury, a posteriorly displaced proximal tibial shaft can tent the popliteal artery. In one series of 30 proximal tibial epiphyseal injuries, 16 (53 percent) were displaced and three had peripheral ischemia at presentation [8]. In another series of 39 proximal tibial epiphyseal fractures, two patients had popliteal artery disruption [15]. Good outcomes require prompt recognition of vascular compromise with emergent operative fracture reduction and vascular exploration.

●Growth disturbance – Accelerated longitudinal growth after a proximal tibial fracture is less common than with femur fractures, but children less than 10 years of age and those with comminution are at potential risk for overgrowth and leg length discrepancy [16,17].

OUTCOMES — Most children have full recovery of function after proximal tibial fractures. Children with complete or greenstick metaphyseal fractures, or fractures complicated by vascular insufficiency, are at the greatest risk for complications. (See 'Complications' above.)

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of acute fracture management".)

●(See "General principles of definitive fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Lower extremity fractures in children" and "Society guideline links: Acute pain management" and "Society guideline links: Child abuse and neglect".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: How to care for your child's cast (The Basics)")

●Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Clinical presentation – Children with proximal tibial fractures have pain, swelling, and/or deformity at the site of injury. They usually are unable to ambulate. Proximal physeal tibial fractures are typically high-energy injuries that warrant careful evaluation for compartment syndrome and, less commonly, popliteal artery injury. (See 'Physical findings' above.)

●Radiographic diagnosis – Anterior-posterior (AP) and lateral plain radiographic views of the lower leg, including the knee and ankle, should be obtained in the child with a suspected proximal tibial fracture to establish the diagnosis. Complicated fractures may require additional imaging (eg, computed tomography, magnetic resonance imaging [MRI]) in consultation with a radiologist or orthopedic surgeon to fully characterize the injury. (See 'Radiographic findings' above.)

●Initial management – The patient with a suspected tibial fracture should undergo evaluation and management appropriate to the patient's mechanism of injury and physical findings:

•Vascular compromise – The emergency clinician should promptly identify children with vascular insufficiency caused by popliteal artery tear (figure 8) and obtain an emergency consult from an orthopedic surgeon with appropriate pediatric expertise. Rarely, these children will require partial closed reduction in the emergency department in an attempt to restore distal circulation. Patients who display a cold, white or cyanotic foot despite reduction and fixation require operative exploration and vascular repair. (See 'Vascular compromise' above.)

•Open fractures – In addition to pain management and immobilization, patients with open fractures should receive antibiotics and tetanus prophylaxis (table 3). (See "General principles of fracture management: Early and late complications", section on 'Open fractures'.)

•Acute compartment syndrome – The rapid overview provides clinical findings and treatment for acute compartment syndrome (table 5). Patients with suspected compartment syndrome should have emergency orthopedic consultation; any dressing, splint, cast, or other restrictive covering removed and ensure that the extremity is not elevated. Compartment pressure measurement helps identify patients in need of fasciotomy, the definitive treatment for decompression of all involved compartments. (See "Acute compartment syndrome of the extremities", section on 'Measurement of compartment pressures' and "Acute compartment syndrome of the extremities", section on 'Management'.)

•Uncomplicated fractures – In patients with closed proximal tibial fractures and no sign of neurovascular compromise, initial management focuses on pain control, immobilization of the fracture, and reduction of swelling. (See "Overview of tibial fractures in children", section on 'Initial management'.)

•Child protection – Diagnosis of a metaphyseal fracture (corner or bucket handle fracture) in a toddler is highly suggestive of child abuse and should prompt involvement of an experienced child protection team (eg, social worker, nurse, child abuse specialist). In many parts of the world (including the US, UK, and Australia), a mandatory report to appropriate governmental authorities is also required for cases of suspected abuse. (See "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

●Definitive management – Definitive management of proximal tibial fractures depends on the type of fracture, and the degree of displacement (see 'Definitive care' above):

•Physeal fractures – Treatment depends upon the degree of injury (figure 1) (see 'Physeal fractures' above):

-Nondisplaced Salter-Harris I or II fractures – Splint in mild flexion with orthopedic evaluation in two to three days.

-Displaced Salter-Harris I or II fractures – Urgently consult an orthopedic surgeon with pediatric expertise for closed reduction

-Salter-Harris III or IV fractures – Urgently consult an orthopedic surgeon with pediatric expertise for closed reduction

•Metaphyseal fractures – Metaphyseal fractures warrant prompt orthopedic consultation for casting or operative reduction with fixation depending upon the severity of the injury.

•Tibial spine or tubercle avulsion fractures – Treatment depends upon the degree of displacement (see 'Tibial spine avulsion' above and 'Tibial tubercle avulsion' above):

-Displaced fractures – Tibial tubercle avulsion fractures that are intra-articular or displaced (image 1) or tibial spine fractures with significant displacement require prompt consultation with an orthopedic surgeon with pediatric expertise to determine the need for operative reduction and fixation.

-Nondisplaced fractures – Treatment for patients with nondisplaced proximal tibial spine or tubercle avulsion fractures consists of placement in a knee immobilizer and making the patient nonweightbearing with crutches. These patients may be discharged home with orthopedic follow-up. (See 'Tibial spine avulsion' above and 'Tibial tubercle avulsion' above.)