Overview of tibial fractures in children

INTRODUCTION — Tibial fractures are a common pediatric fracture. Young children and toddlers are at risk for tibial shaft fractures, even when the force of injury is low. The diagnosis should be suspected in all children with a limp or refusal to bear weight.

Physical examination often allows localization of the fracture and should identify the presence of an open fracture or an acute compartment syndrome. Plain radiographs often suffice when assessing acute tibial injuries in children, but selected patients may require other forms of imaging. In patients with closed fractures and no sign of neurovascular compromise, initial management focuses on pain management, immobilization of the fracture, and reduction of swelling.

An overview of tibial fractures in children is presented here. The evaluation and management of specific types of tibial fractures in children is discussed separately. (See "Proximal tibial fractures in children" and "Tibial and fibular shaft fractures in children".)

EPIDEMIOLOGY — Tibial fractures occur commonly in children. The mechanism of injury varies depending on the age of the patient. Low energy falls and twisting injuries account for most fractures in toddlers and younger children. High energy motor vehicle accidents and sports related injuries predominate in older children and adolescents (image 1). The high energy transmitted to the soft tissues surrounding the bone is relevant because of the risk for compartment syndrome associated with tibial fractures. (See 'Acute compartment syndrome' below.)

Most tibial shaft fractures are short oblique or transverse fractures of the middle or distal third of the shaft [1]. Tibial shaft fractures are associated with fibula fractures in 30 percent of cases [2].

Displaced fractures through the proximal tibial physis or metaphysis are relatively rare. With a significant hyperextension injury, posterior displacement of the proximal tibial shaft can disrupt the popliteal artery and cause distal ischemia [3,4]. (See 'Anatomy' below.)

Tibial tubercle fractures are more common in adolescent patients and often require operative management [5].

ANATOMY — The tibia is the major weight-bearing bone of the lower leg (figure 1 and figure 2). The tibial shaft bridges the tibial plateau, the proximal portion of the tibia forming the base of the knee joint, and the distal tibia, comprising the superior articular surface of the ankle joint at the tibiotalar articulation and the medial malleolus.

The tibial tuberosity is a key landmark that is located 1 to 2 cm below the joint line and serves as the attachment site for the patellar tendon [6]. In active older children and young adolescents, it is subject to tensile forces that may lead to chronic inflammation and pain in this apophysis called Osgood-Schlatter disease. (See "Osgood-Schlatter disease (tibial tuberosity avulsion)".)

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'.)

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) border the tibia, but all of the compartments can be compromised by tibial injury.

Nerves and vessels lie within the anterior and the deep posterior compartments, while the lateral compartment contains the superficial peroneal nerve (figure 1 and figure 2 and figure 4). Trauma that causes significant swelling in these compartments can result in neurovascular compromise. Approximately two percent of pediatric tibial fractures result in compartment syndrome [2]. 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 may compromise this blood supply.

The periosteal vessels provide a less vulnerable circulation as they derive an abundant blood supply from the anterior tibial artery, which travels down along the interosseous membrane. Vascular compromise can arise more proximally from marked effusion of the knee joint or trauma that affects the popliteal artery before it branches into the anterior and posterior tibial arteries. Ischemia may also result from impingement of the anterior tibial artery as it branches off the popliteal artery and passes through a gap in the interosseous membrane (figure 2) [6].

The tibial nerve and its branches (posterior tibial and common peroneal) provide the key innervation to the muscles of the lower leg and foot. Nerve roots arise from L4 through S3. The posterior 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 into deep and superficial branches as it courses around the fibular neck. The deep peroneal nerve branches and follows the course of the anterior tibial artery providing innervation to muscles in the anterior lower leg. The superficial peroneal nerve is purely sensory and supplies sensation to the dorsum of the foot.

CLINICAL FEATURES — 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".)

Children with tibial fractures typically present with limp, pain, refusal to bear weight, and/or deformity of the lower extremity. Sports injuries and motor vehicle collisions are common causes of injury in older children and adolescents.

Isolated fractures of the tibia are common in toddlers and often result from low energy falls. However, the tibia is the second most commonly fractured long bone in abused children and therefore, the clinician should ensure that the mechanism of injury matches the severity of the fracture and perform a complete physical examination that searches for other physical signs of child abuse (table 3) [7]. (See "Physical child abuse: Recognition".)

Examination — A complete evaluation of the entire lower extremity should be conducted before assuming that the injury is confined to the tibia, especially in a child who is less than five years of age and/or is nonverbal.

Once other injuries are excluded, the examination can focus on the tibia. Analgesia prior to examination (eg, ibuprofen for mild to moderate pain or intranasal or intravenous [IV] fentanyl or IV morphine for severe pain) will often facilitate the child's cooperation.

Inspection — Clinicians should inspect the injured lower leg for:

●Swelling

●Deformity

●Lacerations or other open wounds suggesting an open fracture with need for urgent intravenous antibiotics and updated tetanus vaccination

●Tense swelling of the skin and muscles possibly indicating acute compartment syndrome

The amount of swelling is not always a reliable guide to the presence of a tibial fracture, especially a toddler's fracture or stress fracture. (See "Tibial and fibular shaft fractures in children".)

Patients with hyperextension injuries and suspicion for proximal tibial fractures are at greater risk for neurovascular compromise. (See "Proximal tibial fractures in children".)

Palpation — Palpation should include all of the bones of the leg, ankle, and foot. Clinicians should palpate the tibia looking for the point of maximal tenderness and assess the hip, knee, and ankle joints for swelling, tenderness, and the presence of effusion.

Neurovascular assessment — Neurovascular findings should be assessed in both legs.

The clinician should palpate the posterior tibial and dorsalis pedis pulse and determine capillary refill in the foot.

Sensory evaluation involves testing of the following nerves in the indicated sites:

●Deep peroneal (fibular) nerve (between the first and second toes on the dorsum)

●Superficial peroneal (fibular) nerve (remainder of the dorsal foot)

●Medial plantar nerve (medial plantar surface from great toe to middle of the fourth toe)

●Lateral plantar nerve (lateral plantar surface from middle of the fourth toe to fifth toe)

●Sural nerve (lateral foot)

●Saphenous nerve (medial foot)

Although pain may interfere with interpretation, the ability to extend and flex the toes tests the deep peroneal (fibular) and tibial nerves, respectively.

Acute compartment syndrome — Elevated pressure due to increased volume within a constricting fascia can cause an acute compartment syndrome. Bleeding from a tibial fracture can extravasate into the posterior, deep posterior, or anterior compartment (figure 4) and elevate the intracompartmental pressure. Involvement of the lateral compartment usually suggests that a fibular injury is also present. (See "Acute compartment syndrome of the extremities".)

The following findings suggest a developing compartment syndrome:

●Excessive swelling and ecchymosis of the lower leg

●Increasing leg pain that is poorly responsive to parenteral analgesia early symptom that should alert the clinician

●Increased pain upon passive extension of the toes

●Tenseness of the affected muscle compartment

●Cold leg and foot with poor perfusion, pallor, and diminished or absent distal pulses (late findings)

In young children who may not communicate pain as effectively, the framework, known as the three "As" has been advanced for clinical signs of compartment syndrome: escalating analgesia use, anxiety, agitation [8].

Children with suspected acute compartment syndrome require emergency consultation with an orthopedic surgeon. While compartment pressure measurement can help guide care, compartment syndrome is a clinical diagnosis and compartment pressures may not need to be measured in an awake patient with a consistent physical examination. (See "Acute compartment syndrome of the extremities", section on 'Management'.)

Imaging — Plain radiographs typically suffice when assessing acute tibial injuries in children and include anterior-posterior (AP) and lateral views. These should incorporate the entire length of the lower leg from knee to ankle. Radiolucent splinting during the procedure reduces the risk of additional injury and allows proper positioning to best visualize fractures.

Although the AP view is the best view for observing non-displaced spiral fractures commonly located in the distal tibia in toddlers (figure 2), oblique views of the tibia may aid in diagnosis when the AP and lateral plain radiographs are not revealing [9]. (See "Tibial and fibular shaft fractures in children", section on 'Toddler's fractures'.)

Important features that can be assessed from the plain radiographs are the following (see "General principles of fracture management: Fracture patterns and description in children"):

●Fracture location and type (eg, transverse, oblique, comminuted)

●Displacement

●Angulation

●Presence of growth plate fracture at the proximal and/or distal tibia (figure 5)

Additional imaging (eg, skeletal survey, computed tomography, bone scintigraphy, magnetic resonance imaging) may be warranted in selected patients. Possible indications include:

●Nonreducible proximal tibial fracture (see "Proximal tibial fractures in children", section on 'Radiographic findings')

●Suspected physical abuse (see "Orthopedic aspects of child abuse", section on 'Radiographic evaluation')

●Febrile child with trauma and concern for bone infection (see "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Advanced imaging')

●Tibial stress fracture

●Distal tibial triplanar and Salter-Harris III or IV fractures (see "Ankle fractures in children", section on 'Other imaging')

CLASSIFICATION — Fractures of the proximal or distal growth plate are classified using the Salter-Harris system (figure 5). (See "General principles of fracture management: Fracture patterns and description in children", section on 'Physeal fracture description' and "Proximal tibial fractures in children", section on 'Physeal fractures'.)

Nonphyseal tibial injuries are classified according to location (proximal, midshaft, or distal). The treatment of tibial fractures by location is discussed in greater detail separately:

●Fractures of the proximal tibia (see "Proximal tibial fractures in children")

●Fractures of the tibial shaft (see "Tibial and fibular shaft fractures in children")

●Fractures of the distal tibial physis and malleolus (see "Ankle fractures in children", section on 'Distal tibia fractures')

INITIAL MANAGEMENT — The general principles of fracture management apply to tibial fractures. The approach to specific tibial fractures is presented separately in the appropriate topic reviews as follows:

●Fractures of the proximal tibia (see "Proximal tibial fractures in children")

●Fractures of the tibial shaft (see "Tibial and fibular shaft fractures in children")

●Fractures of the distal tibial physis and malleolus (see "Ankle fractures in children", section on 'Distal tibia fractures')

Analgesia — Oral analgesia (eg, ibuprofen) may suffice for patients with mild pain who have suffered a nondisplaced tibial fracture, especially a toddler's fracture or buckle fracture. Opioid analgesia (eg, intravenous [IV] morphine or intranasal fentanyl) is most appropriate for initial pain control in patients with moderate to severe pain and should be given prior to radiographic evaluation. Persistent pain despite adequate parenteral opioid administration should prompt the clinician to evaluate the patient carefully for a developing acute compartment syndrome. (See 'Acute compartment syndrome' above and "Pain in children: Approach to pain assessment and overview of management principles", section on 'Opioids' and "Pediatric procedural sedation: Pharmacologic agents", section on 'Fentanyl'.)

Reduction and splinting — The indications for closed or open reduction of a tibial fracture prior to immobilization and the type of immobilization depend upon the fracture characteristics and location and are discussed in detail separately. (See "Tibial and fibular shaft fractures in children", section on 'Definitive care' and "Proximal tibial fractures in children", section on 'Definitive care' and "Ankle fractures in children", section on 'Definitive care'.)

Reduction of swelling — Patients without signs of acute compartment syndrome should have the lower leg elevated above the level of the heart and undergo cold application to minimize swelling. (See 'Acute compartment syndrome' above.)

Further management of tibial fractures varies with the anatomic location of the fracture. (See "Proximal tibial fractures in children" and "Tibial and fibular shaft fractures in children".)

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

●Anatomy – The tibia is the major weight-bearing bone of the lower leg (figure 1 and figure 2). In children, both the tibia and fibula consist of a long portion of bone (the diaphysis) with growth plates at either end (figure 3). (See 'Anatomy' above.)

●Clinical features – Children with tibial fractures typically present with limp, pain, refusal to bear weight, and/or deformity of the lower extremity. Sports injuries and motor vehicle collisions are common mechanisms of injury in older children and adolescents (image 1). Low energy falls and twisting injuries account for most fractures in toddlers and younger children. (See 'Epidemiology' above and 'Clinical features' above.)

The clinician should conduct a complete physical examination with special attention to findings that may suggest multiple trauma, open fracture, acute compartment syndrome, and/or child abuse. (See 'Clinical features' above.)

●Imaging – Plain radiographs typically suffice to identify acute tibial injuries in children and include anterior-posterior (AP) and lateral views. These should incorporate the entire length of the lower leg from knee to ankle. (See 'Imaging' above.)

Fractures of the proximal or distal growth plate are classified using the Salter-Harris system (figure 5). (See 'Classification' above and "General principles of fracture management: Fracture patterns and description in children", section on 'Physeal fracture description'.)

Nonphyseal tibial injuries are classified according to location (proximal, midshaft, or distal). (See 'Classification' above.)

●Initial management – In patients with closed fractures and no sign of neurovascular compromise, initial management focuses on pain management, immobilization of the fracture, and reduction of swelling. (See 'Initial management' above.)

Treatment of tibial fractures by location are discussed in greater detail separately:

•Fractures of the proximal tibial (see "Proximal tibial fractures in children")

•Fractures of the tibial shaft (see "Tibial and fibular shaft fractures in children")

•Fractures of the distal tibial physis and malleolus (see "Ankle fractures in children", section on 'Distal tibia fractures')