Tibial shaft fractures in children: flexible intramedullary nailing in growing children especially weighing 50 kg (110 lbs) or more

Pediatric distal third tibial shaft fractures: a comparison of surgical fixation methods and incidence of concomitant physeal fractures

The purposeof this study was to compare outcomes of operatively treated pediatric distal third tibial shaft fractures fixed with elastic nailing or plate fixation and to evaluate the incidence of concurrent distal tibia physeal fractures. Retrospective review identified skeletally immature patients that underwent operative fixation of distal third tibia fractures at a level 1 children's hospital from 2010 to 2020. Patient and fracture characteristics were recorded. Analysis of treatment outcomes was performed and rates of concurrent distal tibia physeal fractures were evaluated. Of the 214 surgically treated tibial shaft fractures, 43 were distal third fractures. A concurrent distal tibia physeal fracture was present in 32.6% of patients. These were significantly associated with spiral distal third tibial shaft fractures. The presence of concurrent physeal fractures did not affect patient treatment outcomes. Comparing elastic nailing versus open reduction and plating revealed no difference with time to fracture union, time of postoperative immobilization, or time to full weight-bearing. While elastic nailing was associated with increased coronal angulation, translation, and shortening of fractures on initial postoperative imaging, there was no difference in rates of malunion at final follow-up. In our series, there were no differences in treatment outcomes based on fixation method. Our operatively treated distal third tibial shaft fractures had a higher rate of associated distal tibial physeal fractures than previously published in the pediatric orthopedic literature. We recommend careful evaluation of the ankle for concurrent physeal injuries in patients with distal third tibial shaft fractures indicated for operative treatment. Level of evidence: level III therapeutic study - retrospective comparative study.

Elastic Stable Intramedullary Nailing for Treatment of Pediatric Tibial Fractures: A 20-Year Single Center Experience of 132 Cases

Objective: The aim of this study was to analyze the outcomes and complications in children treated with elastic stable intramedullary nailing (ESIN) for tibial fractures. Methods: The study included 132 patients (92 males) with a median age of 11 years (IQR 10, 15) treated with ESIN for displaced tibial shaft fractures or dia-metaphyseal distal tibial fractures from March 2002 to March 2022. The median follow-up was 118.5 months (IQR 74.5, 170). The primary outcome was success rate, while secondary outcomes were the time of bone healing, length of hospital stay, and associated injuries. Demographic data, type and nature of fracture, indication for surgery, healing time, operative time, complications of treatment, and time to implant removal were recorded. Results: Complete radiographic healing was achieved at a median of 7 weeks (IQR 6, 9). Most of the patients (n = 111; 84.1%) had fractures localized in the shaft of the tibia. The most common injuries were acquired by road traffic accidents (n = 42) and by a fall in the same level (n = 29), followed by injuries from sport activities (n = 21) or motorbike accidents (n = 18). Associated injuries were reported in 37 (28%) children. Fractures were closed in the majority of the children (n = 100; 76%), while 32 (24%) children presented with an open fracture. Children with open fractures were significantly older than children with closed fractures (13.5 years (IQR 10, 15) vs. 11 years (IQR 8.5, 14.5); p = 0.031). Furthermore, children with open fractures had a significantly longer hospital stay (7 days (IQR 5, 9) vs. 3 days (IQR 3, 6); p = 0.001), a higher rate of associated injuries (n = 14 (43.7%) vs. n = 23 (23%); p = 0.022), and a higher rate of postoperative complications (n = 7 (21.9%) vs. n = 8 (8%); p = 0.031). No intraoperative complications were recorded. A total of 15 (11.4%) postoperative complications were recorded. Most complications (60%) were minor complications, mostly related to the wound at the nail insertion site and were managed conservatively. A total of six (4.5%) patients required reoperation due to angulation of the fragments (n = 5) or refracture (n = 1). Conclusion: ESIN is a minimally invasive bone surgery technique and is a highly effective treatment for pediatric tibial unstable fractures with a low rate of complications. Based on the given results, surgical stabilization of the tibial fractures using titanium intramedullary nailing can be safely performed without casting with early physiotherapy.