Tibial and fibular shaft fractures in children

INTRODUCTION — The evaluation and management of pediatric tibial and fibular shaft fractures will be reviewed here. The general approach to tibial fractures, care of proximal tibial fractures in children, and stress fractures of the tibia and fibula are discussed separately. (See "Overview of tibial fractures in children" and "Proximal tibial fractures in children" and "Stress fractures of the tibia and fibula".)

EPIDEMIOLOGY — Lower leg fractures occur with an incidence of approximately 11 per 1000 children and are one of the more common lower extremity fractures in children [1,2]. The mechanism varies depending on the age of the patient, with low energy falls and twisting injuries being more common in younger children and high energy motor vehicle accidents and sports-related injuries predominating in older children and adolescents (image 1). The high-energy transmitted to the soft tissues surrounding the bone is relevant because of the significant risk for compartment syndrome associated with tibial shaft fractures. Thus, special attention should be paid to neurovascular status in the first 24 hours following such injuries. Open fractures, most commonly caused by vehicular related injury, are also a major concern with tibial shaft fractures because the anterior tibia is very close to the skin surface.

Most tibial shaft fractures are short oblique or transverse fractures of the middle or distal third of the shaft. Tibial shaft fractures are associated with fibula fractures in 30 percent of cases [3]. The average age at injury is eight years, and it is more common in boys than girls [3,4].

CLINICAL ANATOMY — The tibia is the major weightbearing bone of the lower leg (figure 1 and figure 2). The proximal portion of the bone, the tibial plateau, forms the lower surface of the knee joint. The distal end of the bone forms the superior articular surface of the ankle joint at the tibiotalar articulation and the medial malleolus. The tibial shaft bridges the proximal and distal ends and its anterior surface lies just below the skin.

In children, both the tibia and fibula consist of a long portion of bone (the diaphysis) with growth plates at either end (figure 3). The distal physes, particularly of the fibula, are areas vulnerable to fracture when subjected to inversion and eversion stresses. (See "Ankle fractures in children", section on 'Distal fibula fractures'.)

Pediatric bones have a lower cortical mineral content than adult bones, allowing children's long bones a greater degree of plasticity [5]. Thus, torus fractures and bowing deformities are injuries unique to the pediatric bone. While these injuries occur most commonly in the forearm, they are also seen in the tibia and fibula. (See "General principles of fracture management: Fracture patterns and description in children", section on 'Buckle (torus)' and "General principles of fracture management: Fracture patterns and description in children", section on 'Plastic deformation'.)

A strong fibrous structure, the interosseous membrane, 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. Distally, the interosseous membrane and three ligaments (the anterior, posterior, and transverse tibiofibular ligaments) stabilize the superior ankle joint.

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 4). Three of these (the anterior, posterior, and deep posterior compartments) all border the tibia and can be compromised by tibial injury.

Nerves and vessels lie within the anterior, lateral, and the deep posterior compartments (figure 1 and figure 2 and figure 4). Trauma that causes significant swelling in these compartments can result in neurovascular compromise. The key blood supply of the tibia arises from periosteal vessels and the nutrient artery. The nutrient artery originates from the posterior tibial artery and enters the posterolateral cortex at the middle third of the tibial shaft near the origin of the soleus muscle. Fractures in this region have the potential to compromise this blood supply.

Other aspects of tibial anatomy are described in greater detail separately. (See "Overview of tibial fractures in children".)

MECHANISM OF INJURY — For unintentional injuries, variation in deforming force and patient susceptibility lead to different fracture patterns in the lower leg:

●Spiral (toddler's) and oblique fractures – Most of these injuries occur in children under 11 years of age when the child's body rotates around a fixed foot. In older children, the force is often substantial (eg, skiing, contact sports) and may involve the tibia and fibula. However, in toddlers this injury often results from relatively minor trauma of which the caregiver may be unaware or may dismiss as trivial (image 2). Typically, the tibia is the only affected bone.

●Transverse fractures – These fractures result from a direct blow to the lower leg that is perpendicular to the bone shaft and indicates a high degree of force (eg, motor vehicle collision) (image 1).

●Bowing fractures – Plastic bowing fractures are caused by axial loading that creates microfractures along the cortex and abnormal curvature of the bone [6]. These fractures are more common in the radius and ulna but are also common in the fibula and can be associated with spiral tibial fractures. The abnormality may be subtle, requiring comparison views to detect on plain radiographs. (See "General principles of fracture management: Fracture patterns and description in children", section on 'Plastic deformation'.)

●Torus (buckle) fractures – Torus fractures (also known as buckle fractures) are caused by compressive forces that lead to buckling of the cortex. (See "General principles of fracture management: Fracture patterns and description in children", section on 'Buckle (torus)'.)

●Fibular fractures – Approximately 30 percent of tibial fractures have an associated fibular fracture. Isolated fibular fractures indicate a direct blow to the lateral aspect of the lower leg.

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 tibial and/or fibular shaft fractures may have pain, swelling, and/or deformity at the site of injury. Most patients are unable or unwilling to walk, with the exception of those children with an isolated fibular fracture.

Additional findings of specific fractures are as follows:

●Oblique or transverse fractures – These fractures are more likely to be open and are also at higher risk for compartment syndrome because of the high-energy mechanisms involved. Thus, careful examination for a puncture wound or laceration overlying the fracture and assessment of distal neurovascular status should occur. (See "Overview of tibial fractures in children", section on 'Clinical features' and "Overview of tibial fractures in children", section on 'Acute compartment syndrome'.)

●Toddler's fractures – These children typically have a markedly limp or refuse to bear weight on the affected extremity. There is usually no swelling or deformity of the distal tibia to guide the clinician to the site of injury. In cooperative children, tenderness to palpation is often found over the distal tibia. Tenderness may also occur when the provider places one hand at the knee, the other at the ankle, and gently twists in opposite directions. Alternatively, the provider can gently apply back-and-forth pressure to the heel of the foot and into the distal tibia.

Eliciting localized tenderness over the site of injury may be difficult, particularly in a child who is already crying. In these patients, the clinical findings of limp or refusal to bear weight may be the main clue to the injury.

The full range of motion at the hips, knees, and ankles should also be assessed and is preserved in children with toddler's fractures.

●Bowing or torus (buckle) fractures – Often, there is no swelling or minimal swelling at the fracture site. Patients with a torus fracture typically have identifiable bony point tenderness. Plastic deformation is visible only with significant angulation of the fracture although comparison with the unaffected side may allow detection of subtle differences.

●Identifying abusive injuries – Transverse fractures of the femur, humerus, or tibia are the most common type of long bone fracture associated with abuse, comprising 48 to 71 percent of abuse-related fractures in various studies. Thus, child abuse should be suspected when the reported mechanism does not correlate with the degree of injury. (See "Orthopedic aspects of child abuse", section on 'Location and type of fracture'.)

In differentiating unintentional from abusive trauma in toddlers with spiral fractures, the clinician should understand that 90 to 95 percent of unintentional toddler's fractures of the tibia have a reported mechanism [7-9]. In these instances, the described force is typically low energy, and the fracture is minimally displaced. For example, the toddler may stumble and catch the foot between the bars of a crib, or may slip on toys on the floor while running. Like all long bone fractures, spiral fractures are suspicious (but not pathognomonic) for abuse when the patient is too young to walk or lacks a consistent history (ie, of having had a twisting or rotational injury). (See "Orthopedic aspects of child abuse", section on 'Location and type of fracture'.)

RADIOGRAPHIC FINDINGS — Anterior-posterior (AP) and lateral plain radiographic views of the lower leg, including the knee and ankle, constitute the initial imaging of choice in the child with a suspected tibial and/or fibular shaft fracture.

Based on the radiographic findings, tibial and/or fibular shaft fractures are classified by diaphyseal location (proximal, middle, or distal third), configuration (transverse, oblique, spiral), angulation, amount of displacement, degree of comminution, and degree of shortening.

Additional radiographic features by type of injury are listed below.

Toddler's fractures — Toddler's fractures are a specialized case of spiral fractures of the distal tibia. The toddler's fracture is a nondisplaced fracture of the distal tibial shaft in patients in the age group from nine months, when weight bearing is just beginning, to approximately four years [10,11]. The definition of toddler's fractures can be expanded to include fractures of other lower extremity bones including fractures of the foot and fibula, but the tibia is the most commonly affected bone because it bears most of the weight of the lower leg [6,12,13]. The physical examination findings usually are subtle.

AP and lateral radiographs of the affected leg may show a faint hairline fracture that can be easily missed, mistaken for a nutrient vessel, or inapparent on initial films in almost a third of patients [9]. The AP view is the best view for observing the nondisplaced spiral fracture coursing along the distal tibia (image 2). Oblique views of the tibia can aid diagnosis when the AP and lateral plain radiographs are not revealing [8]. In patients with clinical findings suggestive of a toddler's fracture but negative plain radiographs, repeat plain radiographs in seven days often show evidence of new bone growth. (See 'Spiral (toddler's) fractures' below.)

Occasionally, young children present with a limp, but there is diagnostic uncertainty due to lack of reported history, prolonged symptoms, or fever. In these situations, advanced imaging may be warranted, either gadolinium-enhanced magnetic resonance imaging (MRI) if infection is the primary concern or computed tomography (CT) if significant bone destruction is seen on plain film [6]. (See "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Advanced imaging'.)

Bone scintigraphy is very sensitive for toddler's fractures and infections, but it exposes the child to significant amounts of radiation. It may be useful when MRI is not available, the area of infection cannot be localized, or multiple areas of involvement are suspected, especially in patients with atypical presentations [14]. (See "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Scintigraphy'.)

Although operator dependent, extremity ultrasound may show a hypoechoic hematoma along the tibial cortex or elevated periosteum indicative of a toddler's fracture, despite negative radiographs [15].

Bowing fractures — These fractures should be apparent on AP and lateral radiographs. A bowing plastic deformity exists but no clear fracture line is identified. Bone scans may rarely be necessary to confirm the diagnosis in uncertain cases (picture 1).

Torus (buckle) fractures — A buckle fracture typically occurs at the distal metaphysis of the tibia or fibula, where the bone is most porous, usually in younger children (image 3). This injury is caused by buckling of the cortex due to compression failure. Torus fractures may be subtle, especially on the AP view.

Pathologic fracture — Children with neuromuscular diseases, osteogenesis imperfecta, or bone lesions are at risk for tibial or fibular fractures, even after trivial trauma, such as moving from a bed to a wheelchair. The only clinical manifestation of fracture in such cases may be erythema overlying the anterior tibia, which can be confused with cellulitis. (See "Cerebral palsy: Classification and clinical features", section on 'Osteopenia' and "Osteogenesis imperfecta: An overview".)

INITIAL TREATMENT — 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 tibial and/or fibular shaft 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'.)

Open fractures — All pediatric patients with open fractures of the tibia or fibula warrant emergency consultation with an orthopedic surgeon. Patients with type II or higher open fractures (table 3) have a substantial risk for infection and should receive surgical irrigation and debridement. Pending operative care, these patients should also undergo the following treatments (see "General principles of fracture management: Early and late complications", section on 'Open fractures'):

●Immobilization with a long leg splint (see "Basic techniques for splinting of musculoskeletal injuries", section on 'Posterior leg splint')

●Analgesia (eg, intravenous morphine)

●Intravenous antibiotics as determined by the prevalence of methicillin-resistant Staphylococcus aureus in the region (see "Hematogenous osteomyelitis in children: Management", section on 'Children three months and older')

●Tetanus prophylaxis as needed (table 4)

Patients with type I open fractures of the tibia or fibula (ie, clean wound <1 cm in length) usually have minimal soft tissue injury and intact local perfusion. Preliminary evidence suggests that nonoperative treatment of these injuries with irrigation, one dose of intravenous antibiotics, and casting in the emergency department can have good results [16,17]. However, given the limited numbers of patients in these series, further study is needed before nonoperative treatment of these injuries becomes routine. An orthopedic consultation should always be obtained for these patients.

Complications of open fractures of the lower leg can include wound infection, osteomyelitis, and flap failure. Overall, limb salvage rates approach 98 percent [18].

Acute compartment syndrome — Compartment syndrome may rarely occur prior to or after definitive orthopedic care of a tibial shaft 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 syndrome remains a clinical diagnosis. Although compartment pressure measurements can corroborate the clinical suspicion of a compartment syndrome, the patient with clear physical exam signs of a potential compartment syndrome should undergo fasciotomy with 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 tibial shaft fracture in a child, especially a nonambulatory infant, with a questionable mechanism of injury should prompt evaluation for child abuse once the patient is stable (table 5). Consultation with a multidisciplinary child abuse team that includes a child abuse specialist is optimal, where available, and may support transfer to a center with these resources. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management".)

In many parts of the world, 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'.)

Once the patient is stabilized, the medical care team should ensure that any child under two years of age with suspected intentional trauma be thoroughly evaluated, including a funduscopic examination by an ophthalmologist to assess for retinal hemorrhages and a skeletal survey.

The safety of other children in the home must be ensured by local Child Protective Services. (See "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Eye findings in children with abusive head trauma (AHT)".)

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — Prompt orthopedic consultation should be obtained in patients with any of the following tibial or fibular shaft fractures [19]:

●Open fractures

●Fractures complicated by acute compartment syndrome or neurovascular compromise

●Pathologic fractures, especially in patients with spasticity or bone disease (eg, osteogenesis imperfecta)

●Unstable fractures (eg, fracture of the tibia and ipsilateral fibula, fracture of the tibia and ipsilateral femur)

●Displaced tibial fractures (eg, tibial fractures with >10 degrees anterior angulation, >5 degrees of varus or valgus angulation, >1 cm of shortening)

DEFINITIVE CARE — Management of tibial and fibular shaft fractures depends on the bone affected, the type of fracture, and the degree of displacement.

Nondisplaced tibial shaft fractures — With the exception of Toddler's fractures, casting is the mainstay of treatment for nondisplaced tibial shaft fractures in children. Treatment consists of a long leg cast with the knee bent to 45 degrees at the knee and 90 degrees at the ankle for four to six weeks with frequent cast checks, followed by a short leg walking brace for an additional four to six weeks. The patient is ready for normal activity once full radiographic healing is demonstrated, and the fracture site is no longer tender to palpation.

Prompt orthopedic evaluation is warranted for initial casting of children with tibial fractures associated with ipsilateral fibular fractures. However, subsequent treatment is not altered.

Displaced tibial shaft fractures — Displaced tibial fractures require reduction and casting with sedation or general anesthesia (image 1). A short leg cast is applied first with the ankle in gentle plantar flexion. After the short leg cast is set, the rest of the cast is applied to the groin with the knee flexed 30 to 60 degrees. Casts applied during the acute phase of injury should be bivalved to allow for swelling. Post-reduction films should be taken to evaluate the degree of alignment and should be taken weekly for the following three weeks to evaluate for maintenance of reduction.

We suggest that patients who require closed reduction of a tibial shaft fracture be admitted to the hospital to monitor for signs of acute compartment syndrome. This recommendation especially applies to patients with significantly malaligned or displaced fractures [3].

Fibular shaft fractures — Fibula fractures in conjunction with tibial fractures may be unstable and warrant prompt orthopedic evaluation regardless of displacement as previously discussed. (See 'Nondisplaced tibial shaft fractures' above.)

Isolated fibular fractures may be initially managed with a stirrup splint, analgesics, ice, and elevation. The child should see an orthopedist with pediatric expertise within one week. At that time, patients may receive a short leg walking cast. Alternatively, the stirrup splint may be used for the entire period of immobilization, typically three to four weeks.

Although the fibula is not essential to ambulation, children whose fractures are very painful or who are wearing a stirrup splint should be made non-weightbearing with crutches, as capable.

Fibular fractures that involve the ankle joint are discussed separately. (See "Ankle fractures in children".)

Spiral (toddler's) fractures — For children with definite toddler's fractures on plain radiographs (image 2), many experts suggest immobilization with a long leg cast. However, retrospective observational studies suggest that, for spiral fractures of the distal two thirds of the tibia, initial immobilization can be accomplished using a controlled ankle movement (CAM) walker boot or short leg cast with a low risk of fracture instability [20-25]. These same studies included children who did not receive external immobilization and had good outcomes, though the numbers are too small to recommend this approach. Cast immobilization is associated with a significant risk for skin breakdown, longer duration of immobilization, and increased resource use (orthopedic follow-up visits and repeat radiographs) compared with a walking boot. Thus, a walking boot, when available, is preferred. Once immobilized, these patients warrant referral to an orthopedist in 7 to 10 days [20,26-29].

Toddlers with a clear-cut history of trauma and an inability to bear weight on the affected extremity, regardless of negative radiographs, also warrant immobilization with a CAM walker boot, short leg splint or short leg cast. In these patients, a spiral fracture is the most likely cause for the findings and immobilization is appropriate until definitive diagnosis can be made. Such fractures usually become radiographically visible as a result of new bone growth approximately seven days after injury [7].

Bowing or torus (buckle) fractures — Bowing or torus fractures are not displaced and therefore stable (image 3). Both of these fracture types completely heal when immobilized in a short leg cast or splint for three to four weeks. Children are usually made nonambulatory for the first one to two weeks. After that, ambulation, as tolerated, is allowed. Patients are usually referred to an orthopedist for follow-up within one week of the initial injury.

DISCHARGE AND FOLLOW-UP — Patients with nondisplaced tibial fractures should be provided with immobilization (splint or cast) as previously described, made nonambulatory, and instructed to keep the fracture site elevated above the level of the heart as much as possible for the first 48 hours after injury. These patients may be discharged home with orthopedic follow-up in one week. (See 'Nondisplaced tibial shaft fractures' above.)

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

We suggest that patients who require closed reduction of a tibial shaft fracture be admitted to the hospital to monitor for signs of acute compartment syndrome for 24 to 48 hours. This recommendation especially applies to patients with significantly malaligned fractures and those rare patients who need external fixation and pinning [3].

Tibial and/or fibular shaft fractures that undergo closed reduction should be evaluated by an orthopedic surgeon within a week. Subsequently, the patient is seen on a frequent basis for the first few weeks to monitor for any displacement or angulation.

COMPLICATIONS — Complications from tibial and/or fibular fractures are rare. Sequelae of acute compartment syndrome and open fracture are of greatest concern.

●Compartment syndrome – Compartment syndrome in tibial shaft fractures is significantly less common in children than in adults [30]. Direct intracompartmental pressures greater than 30 mmHg can cause irreversible damage to muscle and nerves and can result in permanent disability or limb amputation [3]. Most children and adolescents with early diagnosis and decompression with fasciotomy will not have long-term sequelae [31]. (See "Acute compartment syndrome of the extremities", section on 'Disease course and prognosis'.)

●Poor healing – Open tibial shaft fractures in children have delayed union or nonunion in almost 25 percent of injuries [31]. Infection at the fracture site increases the risk [3]. An unstable fracture site is suggested by progressive angulation of the fracture, limited callus formation, and radiographic lucency at the site of fixator pins [3]. Up to 10 degrees of angular deformity of the tibia in the coronal or sagittal plane in children eight years and younger remodels predictably [32]. Clinically significant limb malunion causing pain or joint problems may require corrective osteotomy. Rotational malunion does not remodel and may result in gait disturbance or abnormal limb appearance, which may require surgery [3].

Delayed bone healing, malunion, or nonunion is rare with closed tibial shaft fractures.

●Growth disturbance – Accelerated longitudinal growth after a tibial shaft fracture and subsequent leg length discrepancy is less common than with femur fractures, but children less than 10 years of age and those with comminution are at greatest risk for overgrowth [3,4].

OUTCOMES — Most children with tibial and/or fibular shaft fractures have excellent long-term outcomes. Patients with open fractures or compartment syndrome are at greatest risk for poor healing and infectious 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 topics (see "Patient education: How to care for your child's cast (The Basics)" and "Patient education: How to use crutches (The Basics)")

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

SUMMARY AND RECOMMENDATIONS

●Epidemiology – Tibial shaft fractures are common in children. Young children may develop nondisplaced fractures after low energy falls and twisting injuries. High energy motor vehicle accidents and sports-related injuries are the typical mechanisms of injury in older children and adolescents (image 1). (See 'Epidemiology' above and 'Mechanism of injury' above.)

●Clinical manifestations – Children with tibial and fibular shaft fractures may have pain, swelling, and/or deformity at the site of injury and are usually unable or unwilling to walk; children with an isolated fibular fracture may be able to walk with a limp. (See 'Physical findings' above.)

Oblique or transverse tibial shaft fractures may be complicated by an open fracture or acute compartment syndrome. (See 'Physical findings' above.)

Children with torus, bowing, or toddler's fractures (nondisplaced spiral fractures of the tibial shaft) may have minimal swelling. Bony tenderness is typically elicited in older, verbal children with torus or bowing fractures. Toddler's fractures may be difficult to localize due to the infant or young children's lack of cooperation or ability to communicate. (See 'Physical findings' above.)

●Imaging – Anterior-posterior (AP) and lateral plain radiographic views of the lower leg, including the knee and ankle, provide appropriate initial imaging in the child with a suspected tibial and/or fibular shaft fracture and confirm the diagnosis. (See 'Radiographic findings' above.)

●Initial treatment – In patients with closed tibial and/or fibular shaft fractures and no sign of neurovascular compromise or multiple trauma, 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'.)

●Open fractures – In addition to pain management and immobilization, patients with open fractures require emergency orthopedic consultation, intravenous antibiotics, and tetanus prophylaxis (table 4). (See 'Open fractures' above.)

●Definitive care – Definitive management of displaced tibial and/or fibular shaft fractures depends on the bone affected, the type of fracture, and the degree of displacement. (See 'Definitive care' above.)

•Indications for orthopedic consultation – The following injuries warrant emergency orthopedic consultation (see 'Indications for orthopedic consultation or referral' above):

-Displaced or unstable tibial shaft fractures (image 1) (see 'Displaced tibial shaft fractures' above and 'Fibular shaft fractures' above)

-Pathologic fractures (see "General principles of fracture management: Fracture patterns and description in children", section on 'Pathologic fracture')

-Open fractures (see 'Open fractures' above)

-Fractures complicated by acute compartment syndrome or neurovascular compromise

For patients with a suspected compartment syndrome, any dressing, splint, cast, or other restrictive covering should be removed. The limb should not be elevated. (See 'Acute compartment syndrome' above and "Acute compartment syndrome of the extremities".)

We suggest that patients who require closed reduction or operative care of a tibial shaft fracture be admitted to the hospital to monitor for signs of acute compartment syndrome for 24 to 48 hours (Grade 2C). (See 'Discharge and follow-up' above.)

•Nondisplaced fractures – Patients with nondisplaced tibial fractures (image 3) should be provided with immobilization (splint or cast), made nonambulatory, and instructed to keep the fracture site elevated above the level of the heart as much as possible for the first 48 hours after injury. These patients may be discharged home with orthopedic follow-up arranged within 7 to 10 days of the day of injury. (See 'Definitive care' above and 'Discharge and follow-up' above.)

•Spiral (toddler's fractures) – Toddler's fractures represent a specific type of tibia fracture. The classic toddler's fracture, defined as a nondisplaced spiral fracture of the distal two thirds of the tibia (image 2), may be treated less conservatively. Some orthopedic and pediatric emergency medicine practitioners may choose to place these children in a short leg cast, splint, or walking boot to control ankle movement (CAM). The evidence for this approach is limited to small studies. The standard practice remains full immobilization with a long leg cast or splint.

●Child protection – Diagnosis of a tibial shaft fracture in a child, especially a nonambulatory infant, with a questionable mechanism of injury should prompt evaluation for child abuse (table 5). Consultation with a multidisciplinary child abuse team that includes a child abuse specialist is optimal, where available, and may support transfer to a center with these resources. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management".)

In many parts of the world, a mandatory report to appropriate governmental authorities is also required for cases of suspected abuse. Additional evaluation for other injuries is also indicated. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)