SUPPLEMENT ARTICLE
The Community Orthopaedic Surgeon Taking Trauma Call:
Pediatric Tibia Fracture Pearls and Pitfalls
Steven A. Lovejoy, MD* and Charles T. Mehlman, DO, MPH†
Summary: Tibial fractures in children present a wide array of
challenges to the managing orthopaedic surgeon. Injuries cover
a spectrum from subtle tibial spine fractures to comminuted high-
energy shaft fractures requiring free flap coverage. Significant risks
range from malunion and leg length discrepancy to infected
nonunions and Volkmann ischemic contracture. This article offers
evidence and experience-based advice that is aimed at helping the
community orthopaedic surgeon taking call.
Key Words: tibia, tubercle, fracture, tibial spine, toddler
(J Orthop Trauma 2017;31:S22–S26)
INTRODUCTION
This article focuses on pediatric tibial fractures (including
AO-OTA 41-E, 41-M, and 42-D).1 Children’s tibia fractures
can be thought of in several different categories. Open versus
closed, high energy versus low energy, growth plate injury
versus diaphyseal, and pulseless versus pink with pulses. The
evaluation of the child with injury starts with the emergency
department phone call. The injury spectrum can run from
ground-level fall to high-speed motor vehicle accident with
ejection or pinned in with prolonged extrication.
VASCULAR INJURY
A critical yet obvious aspect of lower extremity injury
assessment is determining whether you are dealing with
a pulseless foot or not. The position of the foot is important
in this evaluation because of potential kinking of the vessels
with significantly displaced tibia fractures. This can be
remedied with urgent reduction and splinting of angulated
fractures. Palpable pulses distal to the fracture are reassuring.
Pulses that are identifiable only by Doppler still represent an
Accepted for publication August 18, 2017.
From the *Orthopedics and Rehabilitation, Monroe Carell Jr Children’s
Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville,
TN; and †Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s
Hospital Medical Center, University of Cincinnati College of Medicine, Cin-
cinnati, OH.
C. T. Mehlman has received royalties from Oakstone Medical Publishing. No
monetary or nonmonetary support was received regarding the writing/
preparation of this article. The remaining author reports no conflict of
interest.
Reprints: Steven A. Lovejoy, MD, Doctor’s Office Tower, 4th Floor, 2200
Children’s Way, Nashville, TN 37232-9565 (e-mail: steven.lovejoy@
vanderbilt.edu).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000001017
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Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
abnormal vascular examination and are concerning. A
blanched, pulseless foot is an emergency. Appropriate reassess-
ment is necessary after gentle and preferably sedated reduction.
Radiographically benign appearing proximal tibia
injury can be deceiving because vascular injury may still
coexist.2 Physeal injury of the proximal tibia can lead to
vascular compromise in the popliteal space simply because
of tethering at the proximal tibia (Fig. 1). The relatively
extreme fracture displacement at the time of injury may also
have never been captured radiographically. Incomplete ossi-
fication of the proximal tibial epiphysis in younger patients
may also create more subtle bony findings. In a child with
decreased or absent pulses in the lower leg without obvious
fracture suspect a proximal tibial physeal injury. Comparison
to the uninjured side, ankle-brachial index ,0.9, Doppler
duplex ultrasound, and computed tomographic angiography
(CTA) have all been shown to be sensitive to vascular injury.3
CTA is efficient and most often dovetails with other computed
tomography studies performed in the multiple trauma setting.
Vascular surgery involvement should be preemptive on
2 different levels. First, know your consultant. Second,
involving the vascular surgeon when strong suspicion is
entertained allows for the most efficient use of time during the
workup. Testing such as CTA versus intraoperative arterio-
gram can be obtained at the individual preference of your
vascular surgeon. Internal fixation or spanning external
fixation is appropriate for the emergent stabilization in
conjunction with vascular repair. With physeal injuries of
the proximal tibia, reduction and cross pinning in the younger
child can be effective for fixation (Fig. 2).
COMPARTMENT SYNDROME
In the emergency department setting, the suspicion for
the diagnosis of acute compartment syndrome is driven by the
timing and history of injury. Compartment syndrome in
a fracture or injury less than a few hours old is unlikely in
the face of a perfused limb. Crush injury can be an exception.
Delayed presentation from injury is more concerning. Initial
pain out of proportion to injury or increasing pain is a key
complaint. The usual P’s (including pain, paresthesia, pallor,
pulselessness, etc.) of adult compartment syndrome are unre-
liable in children. Thus, assessing the child’s psychological
state (anxiety, apprehension, and general degree of comfort)
and whether or not there are increasing analgesic demands
that carry much greater weight regarding clinical decision-
making.4 Increasing analgesic demands may be considered
the single most important early warning sign of pediatric
posttraumatic compartment syndrome.
J Orthop Trauma  Volume 31, Number 11 Supplement, November 2017
FIGURE 1. Arterial injury from proximal tibia fracture.
A history of medication use known to alter the clotting
cascade or underlying history of a clotting disorder such as
hemophilia should alert the surgeon to the possibility of
compartment syndrome with low-energy injury. Factor replace-
ment to prevent intracompartmental bleeding should be
expedited. Splinting acutely helps clot formation as well. With
FIGURE 2. Proximal tibia Salter–
Harris 2 fracture. A, Initial displace-
ment maximal on lateral image. B,
Status after reduction and pinning.
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Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Pediatric Tibia Fracture Pearls and Pitfalls
high-energy tibia fractures, that is, sports-related, a fall from
height, and motor vehicle accidents (bicycle included) hospital
observation after treatment, closed or open, with limb elevation
should be included with careful monitoring of limb pain.
Compartment pressures have not been specifically validated for
the very young child, but absolute pressures greater than 30–
40 mm Hg or delta P value less than 20 (diastolic pressure
minus compartment pressure) require treatment with appro-
priate compartment fasciotomies. Formal compartment pres-
sure measurements are typically performed with sedation or
anesthesia in the operating room with the surgeon prepared to
perform compartment releases under the same anesthetic.
TIBIAL SPINE FRACTURE
Anterior tibial spine fractures typically present with a knee
hemarthrosis. The history can include sudden deceleration
injuries, such as motorcycle or 4 wheeler mishaps, or twisting
injuries similar to anterior cruciate ligament tears in the older
population. In the child with hemarthrosis and ecchymosis about
the knee, with or without contact injury, look carefully at the
anterior tibial spine. This is best seen on lateral view. Non-
displaced fractures can be treated with a cylinder cast or brace
with the knee in gentle flexion (10 degrees). Displaced fractures
can be splinted and fixed electively with either suture or screw
technique (Fig. 3). All fracture types can benefit from knee
aspiration in the emergency department setting to decrease the
pain associated with pressure from the hemarthrosis.
TIBIAL TUBERCLE FRACTURE
Tibial tubercle fractures are avulsion fractures typically
characterized by tensile loading of the quadriceps muscle with
the knee in slight to moderate flexion. Typical history is of
rebounding a basketball or jumping off a diving board.
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Lovejoy and Mehlman J Orthop Trauma  Volume 31, Number 11 Supplement, November 2017

FIGURE 3. Anterior tibial spine

fracture. A, Initial displacement
easily seen on lateral image. B,
Status after reduction and screw
fixation.

Nondisplaced fractures can be treated with casting with the knee
in full extension. Displacement needs operative fixation typically
with at least 2 screws oriented from front to back compressing
the fracture. An anterior approach is used to remove the thick
periosteum that often blocks reduction of the tibial tubercle.
Limited anterior compartment fasciotomy should be performed.
Very young patients need to be followed for recurvatum
deformity from a growth arrest.5 Significantly displaced fractures
can tent the skin over the anterior tibia and require more urgent
reduction, closed or open to prevent skin breakdown (Fig. 4).
PROXIMAL TIBIA PHYSEAL FRACTURES &
PROXIMAL METAPHYSEAL
Salter–Harris injury patterns of the proximal tibia can
be subtle with small metaphyseal fragments as the only clue
to proximal physeal injury. These are often high-energy frac-
tures, and attention to vascularity of the leg is crucial. Physeal
arrest is the most common complication associated with these
injuries. Periosteum and pes anserine entrapment are common
blocks to reduction. These fractures should be followed dur-
ing growth looking for evidence of deformity because of
physeal arrest. Closed reduction can be performed and held
with casting in a small percentage of cases. If the fracture is
unstable, screws in the metaphyseal fragment or, in the very
young child, cross pinning is used to maintain reduction
(Fig. 2). The fibula usually remains intact.
Proximal metaphyseal fractures of the tibia typically
occur in the 1 to 6-year-old age range. It is important to
recognize that even undisplaced versions of these injuries can
cause growth disturbance although they are extra physeal,
with posttraumatic tibia valga being the most common

FIGURE 4. Tibial tubercle fracture.

A, Displaced tibial tubercle fracture
with intra-articular extension. B,
Status after open reduction and
internal fixation.

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J Orthop Trauma  Volume 31, Number 11 Supplement, November 2017
TABLE 1. Age-Based Acceptable Reduction Criteria for Tibial
Shaft Fractures10
,8-year-old ‡8-year-old
Apex anterior angulation 10 degrees 5 degrees
Apex posterior angulation 5 degrees 0 degrees
Rotation 5 degrees 5 degrees
Shortening 10 millimeters 5 millimeters
Valgus angulation 5 degrees 5 degrees
Varus angulation 10 degrees 5 degrees
deformity. This is called the Cozen phenomena. The key here
is to educate families at initial contact about the nature of this
fracture.6 Some veteran pediatric orthopaedic trauma sur-
geons have also seen great value in treating these fractures
with a high above knee cast with the knee in full extension
and a bit of a varus mold built into the cast. If posttraumatic
tibia valga develops despite these efforts, resolution of the
deformity with further growth usually occurs. Guided growth
can be used in rare cases if the deformity persists.
DIAPHYSEAL & DISTAL
METAPHYSEAL FRACTURES
Tibial diaphyseal and distal metaphyseal fractures can
be low or high energy. Low-energy fractures often are
associated with a history of a fall (sometimes unwitnessed)
from floor height or furniture level. These typically occur in
the toddler to preschool age group. These low-energy
fractures have an event or “time zero” of when the child
stops walking. Be aware of the child who starts with a limp
and progresses to nonweight bearing. Look for constitu-
tional signs and the proverbial “sick kid”, as infectious eti-
ologies can also be a distinct possibility (hematogenous
osteomyelitis or joint infection). Key examination points
for infection are decreased range of motion of joints, irrita-
ble child, and guarding versus point tenderness in the limb
that moves.
Children with toddler’s fractures often sit comfortably
in the parent’s lap, refuse to weight bear, and are point
tender. These fractures often have minimal swelling and
FIGURE 5. Rotational malalignment.
A, Acceptable radiographic align-
ment. B, Unacceptable clinical rota-
tional alignment.
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Pediatric Tibia Fracture Pearls and Pitfalls
ecchymosis. Radiographic examination usually shows a sta-
ble undisplaced spiral to oblique fracture pattern or no acute
x-ray findings at all. These fractures are treated for comfort.
Walker boots to short leg casts can be used to treat patient’s
symptoms. Weight bearing as tolerated is allowed with ces-
sation of immobilization at a month. No further x-rays are
needed.7
HIGH-ENERGY TIBIAL SHAFT FRACTURES
High-energy tibia shaft fractures are more common in
the preteen and teen age groups. Causes include sport injury
(think shin to shin contact in soccer), fall from a height such
as monkey bars, jungle gyms, or climbing walls, or moving
vehicle accidents including bicycles. Some authors have
suggested that Grade 1 open fractures with minimal
contamination can be treated with local wound care, anti-
biotics, and fracture immobilization.8 However, in the au-
thors’ opinions formal operating room washout of grade 1
open fractures should currently remain the norm. The imme-
diate institution of appropriate antibiotic therapy is certainly
one of the important factors in preventing infection in open
fractures. Grade 2 and 3 injuries require more extensive
operative irrigation, debridement, and fracture care.9 The
time to wound closure is dependent on the wound. After
irrigation and debridement of clean contaminated wounds,
consideration can be given to primary wound closure (if
wound tension is minimal) versus closure of surgical exten-
sions of the traumatic wound and inclusion of a wound drain
exiting from the open fracture wound site. Closed treatment
of open fractures follows the same guidelines as closed in-
juries. Adequate reduction of tibia shaft fractures can be
performed, casted, and windowed for wound care. Guide-
lines for acceptable tibial shaft reduction are age-related and
reasonably strict because of the tendency for the tibia to
show its deformity (minimal nature of anteromedial soft-
tissue envelope) (Table 1).10
Sedation and relaxation are key in tibial shaft fracture
reduction. Avoid recurvatum of those fractures near the distal
metaphyseal–diaphyseal junction by allowing the ankle to
plantarflex with reduction (these have been called Gillespie
fractures). Address rotational deformity by aligning ante-
rosuperior iliac spine, patella and second toe. Be sure to
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Lovejoy and Mehlman J Orthop Trauma  Volume 31, Number 11 Supplement, November 2017
compare the contralateral side to account for any preexisting
tibial rotation (Fig. 5). High-energy fractures or worrisome
fractures for swelling should be admitted, elevated, iced, and
serially evaluated. The cast should be bivalved to decrease
external pressure. BEWARE THE INCREASING NAR-
COTIC NEEED FOR COMFORT as an early sign of com-
partment syndrome.
Operative fixation in skeletally immature patients must
avoid the proximal and distal physes. Titanium elastic nails
inserted antegrade from the proximal tibial metaphysis, medial
and lateral, are the workhorse for length stable and open
fractures.11,12 These can be inserted with minimal soft-tissue
dissection. Interposed periosteum and muscle can block reduc-
tion. Cutting the nails flush to the flair of the tibial metaphysis
allows for recommended nail removal at healing (typically 6–
12 months). Plating is rarely used because of prominence of
anterior and lateral plate approaches. A posterior lateral
approach is safe, covers the hardware well, and is indicated
for fractures of the distal 1/2 of the shaft. External fixation
is not recommended due to high nonunion and re-fracture
rates. Splinting after elastic nailing can be used until early
healing provides additional rotational control and comfort
for the child.
CONCLUSIONS
Tibia fractures rank among the most common and
challenging pediatric fractures. The aim of this article was to
cover some of what the authors consider to be the most
important pearls and pitfalls regarding the most common types
of tibial fractures. Quite clearly this was not an exhaustive
discussion of all possible types of tibial fractures; this was not
our intention. However, it is our hope that one or more of the
evidence and experience-based bits of advice offered in this
article will be helpful to our on-call orthopaedic colleagues as
they care for children.
TOP 5 TIBIA FRACTURE PEARLS
1. Casting is still a good option for many tibia fractures.
Assess rotation clinically.
2. Tibia fractures with an intact fibula want to fall into varus.
3. Immediate internal fixations in clean contaminated frac-
tures in children is safe.
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4. Educate families early and often about fractures prone to
growth disturbance.
5. Follow unstable fractures in casts weekly till stable.
TOP 5 PITFALLS OF TIBIA FRACTURES
1. Beware of vascular injury about the knee in tibial injuries.
2. Be vigilant about diagnosing and treating compartment
syndrome.
3. Be aware and educate families about Cozen phenomena in
proximal tibial metaphyseal fractures.
4. Look for subtle fractures about the proximal tibia in post-
traumatic hemarthroses.
5. Avoid recurvatum in shaft and distal metaphyseal fractures
by allowing the foot to plantarflex with closed reduction.
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