ORIGINAL ARTICLE
Displaced Tibial Shaft Fractures With Intact Fibula in Children: Nonoperative Management Versus Operative Treatment With Elastic Stable Intramedullary Nailing Federico Canavese, MD, PhD,* Alexei Botnari, MD,* Antonio Andreacchio, MD,w Lorenza Marengo, MD,w Antoine Samba, MD,* Alain Dimeglio, MD,z Bruno Pereira, PhD,y Mounira Mansour, MD,* and Marie Rousset, MD*
Background: The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced tibial shaft fractures with intact fibula in children after nonoperative management and operative treatment by elastic stable intramedullary nailing. Methods: A study was performed on 80 consecutive children, 56 males, 24 females from 2 Institutions, with displaced and closed tibial shaft fracture with intact fibula. All patients underwent regular clinical and radiographic follow-up visits for at least 2 years after injury. Results: In total, 26 patients (group A-Institution I) were treated surgically by elastic stable intramedullary nailing and 54 patients (18 patients from group B-Institution I and 36 patients from group C-Institution II) were treated nonoperatively with closed reduction and casting. groups A, B, and C did not significantly differ on sex (P = 0.37), side (P = 0.54), and fracture site (P = 0.14). Valgus deformity was significantly controlled in group A patients only (P = 0.001); during follow-up in group B patients (P = 0.017), and showed no significant change between pretreatment images and last follow-up in group C patients (P = 0.71). Procurvatum deformity was significantly controlled in group A patients only (P = 0.001); it showed no significant improvement after conservative treatment in group B (P = 0.73) and C patients (P = 0.8). Recurvatum was significantly improved in group A (P < 0.001) and C patients (P < 0.001) but remained unchanged in group B patients (P = 0.15). Varus deformity improved significantly in all patient groups. Immobilization time was significantly shorter in group A compared with group B and C patients (P < 0.001). However, numerical differences, although statistically significant, were not clinically relevant for all variables but immobilization time.
From the *Pediatric Orthopedic Department, Estaing University Hospital; yBiostatistics Unit, DRCI, Estaing University Hospital, Clermont-Ferrand; zFaculty of Medicine, Montpellier University, Montpellier, France; and wPediatric Orthopedic Department, Regina Margherita Children’s Hospital, Turin, Italy. None of the authors received financial support for this study. The authors declare no conflicts of interest. Reprints: Federico Canavese, MD, PhD, Pediatric Orthopedic Department, Estaing University Hospital, 1, Place Lucie et Raymond Aubrac, Clermont-Ferrand 63003, France. E-mail: canavese_ [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Conclusions: This study showed good functional and radiologic outcomes in the pediatric population who had sustained closed, traumatic, displaced fracture of tibial diaphysis without associated fibula fracture. On the basis of the findings reported here, it is not contraindicated to operate skeletally immature patients with displaced fracture of tibial diaphysis without associated fibula fracture. However, results were essentially the same and either method is a satisfactory choice for pediatric tibia shaft fractures with an intact fibula. In particular, we found that conservative treatment was as efficacious as surgical treatment apart from the length of time for immobilization. Level of Evidence: Level III. Key Words: tibia fracture, children, isolated, conservative, elastic stable intramedullary nailing (J Pediatr Orthop 2015;00:000–000)
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solated tibial shaft fractures in children are relatively common. In the pediatric population, isolated tibial shaft fractures account for about 75% of all tibia fractures and are associated with fibula fracture in about onethird of cases.1–5 Closed reduction and above-knee casting is the mainstay of treatment for isolated tibial shaft fractures.1,2,6 However, Gordon and O’Donnell7 reported that a relative indication for surgical stabilization in children with tibial fracture includes an intact fibula. Surgical treatment options include elastic stable intramedullary nailing (ESIN),4,8–10 Kirschner wire fixation,3 external fixation,10–12 and locked intramedullary nail fixation in patients with closed physis.13 ESIN has recently emerged as a safe and efficient method for the treatment of displaced long bone fractures, including tibial shaft fractures.4,8–10 ESIN provides stable fixation, good rotational stability, and relatively easy insertion and removal.4 However, although the ESIN technique as described by Ligier et al8 is minimally invasive, easy to learn, and has a low complication rate,7 tibial shaft fractures can prove problematic due to the tendency to displace.13–15 Tibial shaft fractures can be managed nonoperatively by closed reduction and casting or operatively by ESIN. Although both management options are widely
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used, there has been no published comparison of the outcomes of isolated tibial shaft fractures treated conservatively versus with ESIN. Dwyer et al16 have investigated the tolerance of malunion in pediatric tibial fractures and concluded that 10 degrees of varus, 8 degrees of valgus, up to 12 degrees of procurvatum, and 6 degrees of recurvatum are acceptable. However, it is still unclear whether surgical stabilization by ESIN is indicated in certain cases, due to the tendency of such injuries to displace.7,13–16 The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced tibial shaft fractures with intact fibula in children after nonoperative management and operative treatment by ESIN. We retrospectively reviewed our experience with these 2 techniques to determine whether 1 approach emerged as superior.
METHODS The study was performed on 80 consecutive pediatric case, 56 males, 24 females from 2 Institutions, who had displaced and closed tibial shaft fracture with intact fibula to evaluate the effect of type of treatment on clinical and radiologic outcome. Retrospective chart and radiograph review was carried out on all cases of skeletally immature patients with displaced and closed tibial shaft fracture with intact fibula referred to 2 institutions from September 2010 to 2012. All patients underwent regular clinical and radiographic follow-up for at least 2 years after injury. At each follow-up visit, full-length anteroposterior and lateral radiographs were taken of the affected leg to assess ongoing tibia fracture consolidation and detect complications such as secondary displacement, refracture, hardware migration, nonunion, or malunion. Complete fracture healing was defined as a full return to activities of daily living and sports. The study was approved was the Institutional Review Boards of each medical center.
Patients Demographics Chart and radiograph reviews were held on all patients to collect and compile personal and medical history data, that is, sex, age at time of trauma, mechanism of accident, side involved, existence of neurovascular insult, and concomitant diagnoses and treatment. Inclusion criteria were age 15 years old and below, presence of growth plate visible on plain radiographs, radiologically proven tibial shaft fracture without concomitant fibula fracture, and without neurovascular injury. Exclusion criteria were absence of growth plate visible on plain radiographs at the time of injury, tibial shaft fracture associated with fibula fracture, polytraumatized patients presenting with other associated fractures, and/or dislocations.
Treatment: Institution I Patients from the first institution were either treated operatively by ESIN (group A) or by nonoperative
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management (group B). Patients that were operated upon had fractures more displaced initially. Each procedure was performed by the same surgical team. Surgery was performed under general anesthesia with the patient placed supine on the operating table. Fracture was first reduced by closed manipulations under fluoroscopic control, then 2 same-diameter intramedullary elastic nails (Synthes, Etupes, France) were introduced through a 0.5 to 1 cm incision just below the proximal tibia growth plate at the proximal tibial metaphysis. The nails were then advanced beyond the fracture site.4,8–10 A layered wound closure was performed, leaving approximately 1 cm of each nail remaining outside the bone. After surgery, all patients were immobilized in a posterior long leg splint for a period of 3 to 4 weeks. Nonoperative management consisted of closed reduction under sedation and immobilization in an aboveknee cast for 6 weeks followed by short leg cast for a further 6 weeks.
Treatment: Institution II All patients from the second institution (group C) were treated by a conservative approach to isolated tibial shaft fractures involving closed reduction under sedation and immobilization in an above-knee cast for 6 weeks followed by short leg cast for a further 6 weeks. All procedures were performed by the same surgical team.
Radiographic Evaluation All patients underwent full-length anteroposterior and lateral radiographs of the injured leg. The tibial shaft is the area of bone below and above the proximal and distal tibia metaphysis, respectively. Only fractures that occurred in this area and managed either operatively by ESIN or nonoperatively by casting were included (Figs. 1, 2). Using the anteroposterior radiographs, fractures were classified as transverse, oblique, or spiroid on the basis of the relationship between the fracture line and the axis of the tibial shaft. When 3 or more fracture fragments were present, the fracture was classified as comminuted. Anteroposterior radiographs were used to assess varus or valgus deformity according to distal fragment displacement in relation to the axis of the tibial shaft. Lateral radiographs were used to assess degree of recurvatum or procurvatum angulation. Recurvatum is defined as a backward thrust of the angle between the axis of the proximal and distal fragments of the fracture. Procurvatum is the opposite. Radiographs of both Institutions were collected and analyzed by the senior author of this paper. Considering the standardized way of measuring 1 plane angulation on anteroposterior and lateral leg radiographs, no intraobserver and interobserver assessment was made. Moreover, according to our study protocol and our biostatistician’s advice, to avoid intraobserver and interobserver errors, we agreed to have all radiographs reviewed and measured by a single, experienced, rater (pediatric orthopaedic surgeon). Copyright
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Displaced Tibial Shaft Fractures
FIGURE 1. Conservative treatment. Left tibia spiroid fracture in a 8-year-old boy at the time of trauma (A, B) and at 9 months’ follow-up (C, D).
Statistical Analysis Statistical analyses were performed using Stata 13 software (StataCorp LP, College Station, TX). Tests were 2-sided, with a type-I error set at a = 0.05. Patient characteristics were presented as means (± SD) or medians (interquartile range) for continuous data (assumption of normality assessed using the Shapiro-Wilk test) and as number of patients and associated percentages for categorical parameters. Comparisons between independent groups were performed using w2 or Fisher’s exact tests for
categorical variables and using ANOVA or KruskalWallis tests as appropriate (homoscedasticity verified using Bartlett’s test) for quantitative parameters. To study the evolution of correlated repeated data, statistical analyses were performed using mixed models to evaluate fixed-effects group, time-points, and their interactions as fixed effects and to take into account between and withinpatient variability as random effects. Residual normality was checked. According to results observed concerning patient’s age in univariate analysis, an adjustment was
FIGURE 2. Surgical treatment. Right tibia transverse fracture in a 11-year-old boy at the time of trauma (A, B) and at 10 months’ follow-up, after hardware removal (C, D). Copyright
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proposed with this parameter as covariable in previous models. A sensitivity analysis was carried out to study the attrition bias and to characterize the statistical nature of missing data.
RESULTS Across the 2 institutions, 80 children (56 males, 24 females) with displaced and closed fracture of the tibial shaft with intact fibula were identified through charts and radiographic review and met the inclusion criteria.
Patients Demographics Table 1 recaps the demographic data collected. In total, 26 patients from Institution I (group A; 32.5%) were treated surgically by ESIN, whereas 18 patients from Institution I (group B; 22.5%) and 36 patients from Institution II (group C; 45%) were treated nonoperatively with closed reduction and casting. Groups A, B, and C did not significantly differ on sex (P = 0.37), side (P = 0.54), and fracture site (P = 0.14). In addition, groups B and C were comparable on treatment options (Table 1).
Radiologic Outcome Table 1 outlines the preoperative and postoperative isolated tibia fracture characteristics and amount of displacement on anteroposterior and lateral radiographs.
Varus Varus deformity improved significantly in all groups regardless of whether treatment was surgical (P < 0.001) or conservative (P = 0.006 for group B and P < 0.001 for group C). These results were confirmed by significant interaction time group obtained using random-effects model adjusted on age covariable (P < 0.001).
Valgus Valgus deformity was significantly controlled in operated patients (group A) only (P = 0.001). Valgus deformity worsened significantly during follow-up in group B patients (P = 0.017) and showed no significant change between pretreatment images and last follow-up in group C patients (P = 0.71). These results were confirmed by significant interaction time group obtained using randomeffects model adjusted on age covariable (P = 0.007).
Recurvatum Recurvatum improved significantly in group A (P < 0.001) and group C patients (P < 0.001) but remained unchanged in group B patients (P = 0.15). These results were confirmed by significant interaction time group obtained using random-effects model adjusted on age covariable (P < 0.001).
Procurvatum Procurvatum deformity was significantly controlled in operated patients (group A) only (P = 0.001). Procurvatum deformity showed no significant improvement after conservative treatment in group B patients (P = 0.73) and group C patients (P = 0.8). These results were confirmed by significant interaction time group
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obtained using random-effects model adjusted on age covariable (P < 0.001).
Treatment and Immobilization All group A patients were treated with 2 same-diameter elastic nails, ranging from 2 to 4 mm. The operated limb was placed in long-leg posterior splint for 6.6 ± 3.2 weeks. Group B and group C patients undergoing conservative treatment were immobilized in a long-leg cast for 10.9 ± 1.9 and 10 ± 1.5 weeks, respectively. Immobilization time was significantly shorter in group A compared with groups B and C (P < 0.001).
Functional Outcome At last follow-up visit, all patients had returned to previous daily and sport activities without discomfort or difficulty, and range of motion of the injured lower extremity was comparable with that of the contralateral side.
Complications One fracture displaced during orthopaedic treatment (group B) and needed closed reduction and ESIN stabilization under general anesthesia. The fracture eventually healed without any further complication. No other complications were observed in any of the 3 groups.
DISCUSSION Several recent papers support surgical stabilization of closed displaced pediatric fractures of the tibial diaphysis. Surgery is advocated due to fracture pattern instability and failure to maintain reduction in cases treated by cast.1,3,17,18 However, closed reduction and above-knee casting remains the mainstay of treatment for isolated tibial shaft fractures at most institutions.1,2,6 No study to date has compared outcomes in a homogenous case series of skeletally immature patients with displaced and closed tibial shaft fracture with intact fibula between those managed conservatively with closed reduction and casting and those operated by ESIN. This study included 2 groups of skeletally immature patients treated either conservatively or surgically. The 2 groups were homogenous. We found that both procedures have equally clinically acceptable results, with the same rate of additional procedures required and the same amount of angulatory deformity at final follow-up (Table 1). Isolated tibial shaft fractures in children are common lower extremity fractures that can be problematic in certain cases. Yang and Letts19 reviewed 95 cases of isolated tibial shaft fractures in children and highlighted that when displaced, diaphyseal tibial fracture with intact fibula can be difficult to reduce. Moreover, reduction can be difficult to hold in position because of the splinting of the intact fibula. In particular, the intact fibula, acting as a splint, is responsible for varus angulation. Yang and Letts19 suggested close monitoring with weekly anteroposterior and lateral leg radiographs for the first 3 weeks postcast. Moreover, Gordon and O’Donnell7 Copyright
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Displaced Tibial Shaft Fractures
TABLE 1. Patient Demographics and Fracture Characteristics Total (n = 80) Sex, males [n (%)] 56 (70) Age at injury (mean ± SD) (y) 9 ± 3.3 Type of fracture [n (%)] Comminutive 3 (3.8) Spiroid 60 (75.0) Oblique 11 (13.7) Transverse 6 (7.5) Side [n (%)] Right 40 (50) Postoperative immobilization Weeks (mean ± SD) — Preoperative translation (mean ± SD) (%) AP view — LL view — Preoperative angulation (mean ± SD) (deg.) Valgus — Varus — Recurvatum — Procurvatum — Postoperative angulation (mean ± SD) (deg.) Valgus — Varus — Recurvatum — Procurvatum — Final assessment (mean ± SD) (deg.) Valgus — Varus — Recurvatum — Procurvatum — Additional procedure 1 (1.2) [n (%)]
Group A (n = 26; 32.5%)
Group B (n = 18; 22.5%)
Group C (n = 36; 45%)
Groups B+C (n = 54; 67.5%)
17 (65.4) 11.1 ± 3.4
11 (61.1) 7.7 ± 3.7
28 (77.8) 8.2 ± 2.3
39 (72.2) 8.0 ± 2.8
2 (7.7) 15 (57.7) 5 (19.2) 4 (15.4)
0 (0.0) 13 (72.2) 5 (27.8) 0 (0.0)
1 32 1 2
(2.8) (88.8) (2.8) (5.6)
1 (1.9) 45 (83.3) 6 (11.1) 2 (3.7)
12 (46.1)
11 (61.1)
17 (47.2)
28 (51.9)
6.6 ± 3.2
10.9 ± 1.9
10 ± 1.5
10.3 ± 1.7
23 ± 21.7 18.8 ± 15.1
5.1 ± 2.3 5.6 ± 1.7
20.8 ± 13.8 20.2 ± 11.3
13 ± 8.1 12.9 ± 6.5
1.81 ± 2.83 2.69 ± 4.42 3.58 ± 3.95 1.02 ± 1.61
0.33 ± 0.59 2.06 ± 3.46 1.78 ± 2.29 0.50 ± 1.25
0.26 ± 0.79 0.85 ± 1.49 0.82 ± 0.96 0.11 ± 0.52
0.29 ± 0.72 1.25 ± 2.37 1.14 ± 1.58 0.24 ± 0.85
0.61 ± 1.36 0.13 ± 0.69 0.19 ± 0.69 0.00 ± 0.00
2.72 ± 3.10 0.39 ± 0.61 1.22 ± 1.66 0.56 ± 1.34
0.56 ± 1.69 2.67 ± 2.44 0.15 ± 0.52 0.09 ± 0.41
1.28 ± 2.45 1.91 ± 2.29 0.51 ± 1.15 0.25 ± 0.86
0.23 ± 0.59 0.08 ± 0.27 0.69 ± 1.09 0.00 ± 0.00 0
1.78 ± 2.04 0.22 ± 0.55 1.11 ± 1.81 0.39 ± 1.20 1 (1.9)
0.33 ± 0.96 2.76 ± 2.22 1.88 ± 1.57 0.14 ± 0.63
0.81 ± 0.23 1.92 ± 2.19 1.62 ± 1.68 0.22 ± 0.86
Group A: surgical treatment; Group B: conservative treatment, Institution I; Group C: conservative treatment, Institution II. AP indicates anteroposterior; LL, lateral.
reported that relative indications for surgical stabilization include displaced tibia fractures with an intact fibula. Shannak’s15 review of 117 patients with leg fracture found that only 27% (32/117 patients) had isolated tibial diaphyseal fractures, and that about a third of patients with more than 10 degrees of angulation at consolidation did not fully remodel at 3- to 10-year follow-up. Shannak15 also highlighted that in skeletally immature patients, varus deformities can undergo spontaneous correction, whereas valgus deformity and recurvatum, as well as rotational deformities, tend to persist. Dwyer and colleagues reviewed 48 patients below 12 years of age and investigated the tolerance of malunion in such injuries. They found that procurvatum deformity realigned maximally (52.7%), followed by varus (40.9%), valgus (23.9%), and recurvatum (18.5%). They concluded that 10 degrees of varus, 8 degrees of valgus, up to 12 degrees of procurvatum, and 6 degrees of recurvatum are acceptable.16 Here, we did not record any significant valgus and procurvatum remodeling in conservatively treated patients. Moreover, 33.3% of patients conservatively treated showed no significant improvement of recurvatum deformity. Briggs et al20 reviewed a series of 25 cases of displaced isolated tibial shaft fractures in which these injuries represented Copyright
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about a third of all tibial fractures in children aged under 11 years (25/65 patients). They found that secondary displacement can occur during the first 2 to 3 weeks postcast and recommended repeated closed reduction and casting if varus displacement exceeds 5 degrees. Manipulations after that period will fail due to progressive fracture consolidation.20 Here, residual deformity on both frontal (valgus) and coronal planes (procurvatum; recurvatum in 33.3% of conservatively treated patients) occurred only in patients treated by closed reduction and casting. Operated patients showed no sign of secondary displacement in any of the 3 planes of space. Furthermore, operated patients had significantly shorter immobilization time compared with conservatively treated patients (Table 1). The reported rate of failure of cast treatment in isolated diaphyseal tibial fractures leading to unplanned surgical procedure varies between 2% and 5%.7,15,19,20 In our series, 1 of 54 fractures treated conservatively (1.9%) displaced during orthopaedic treatment (group B) and needed closed reduction and ESIN stabilization under general anesthesia. The fracture eventually healed without any further complication. Although we did not observe any complication in surgically treated patients, surgical stabilization by ESIN
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is not free of potential complications. Gordon et al21 observed several complications in their retrospective review of 60 diaphyseal tibia fractures (31 closed and 29 open fractures) treated with ESIN. They reported delayed union in 5 cases (8.3%), malunion in 1 case (1.7%), osteomyelitis in 1 case (1.7%), and nail migration in 2 cases (3.5%). Gordon et al21 concluded that fixation of pediatric diaphyseal fractures with ESIN is effective but complications can arise, particularly in older patients. Similarly, Mashru et al1 and Goodwin et al17 reported significant complications such as nail migration, nonunion, malunion, and compartment syndrome. In our group of patients, the overall rate of complications in ESIN-treated patients was low compared with previously published data. We reviewed a homogenous case series of skeletally immature patients with displaced, isolated, and closed tibial shaft fracture. No open fractures were included. Type of fracture and amount of displacement may thus have led to a lower rate of complications in this patient population. Studies have compared surgical versus conservative management for isolated diaphyseal fractures in adults and found similar results to those reported in children. Bone et al13 conducted an outcome analysis of matched pairs of adult patients and concluded that treating isolated, displaced, and closed fractures of the tibial shaft with closed intramedullary nailing with reaming provides superior functional outcomes compared with casting. Similar findings were later published by Karladani et al.22 On the basis of the findings reported here, it is not contraindicated to operate skeletally immature patients with displaced fracture of tibial diaphysis without associated fibula fracture. However, results were essentially the same and either method is a satisfactory choice for pediatric tibia shaft fractures with an intact fibula. This study showed good functional and radiologic outcomes in the pediatric population who had sustained closed, traumatic, displaced fracture of tibial diaphysis without associated fibula fracture. In particular, we found that conservative treatment was as efficacious as surgical treatment apart from the length of time for immobilization. REFERENCES 1. Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. J Am Acad Orthop Surg. 2005;13: 345–352.
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2. Setter KJ, Palomino KD. Pediatric tibia fracture: current concepts. Curr Opin Pediatr. 2006;18:30–35. 3. Qidawi SA. Intramedullary Kirschner wiring for tibia fractures in children. J Pediatr Orthop. 2011;21:294–297. 4. Srivastava AK, Mehlman CT, Wall EJ, et al. Elastic stable intramedullary nailing of tibial shaft fractures in children. J Pediatr Orthop. 2008;28:152–158. 5. Rodriguez-Merchan CE. Pediatric skeletal trauma: a review and historical perspective. Clin Orthop Rel Res. 2005;432:8–13. 6. Sarmiento A, Sharpe FE, Ebramzadeh E, et al. Factors influencing the outcome of closed tibial fractures treated with functional bracing. Clin Orthop Rel Res. 1995;315:8–24. 7. Gordon JE, O’Donnell J. Tibia fracture: what should be fixed? J Pediatr Orthop. 2012;32:S52–S61. 8. Ligier JN, Me´taizeau JP, Pre´vot J. Closed flexible medullary nailing in pediatric traumatololgy. Chir Pediatr. 1983;24:383–385. 9. Me´taizeau J. Oste´osynthe`se chez l’enfant: embrochage centrome´dullaire e´lastique, stable. Montpellier, France: Sauramps Me´dical; 1988. 10. Kubiak EN, Egol KA, Scher D, et al. Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation? J Bone Joint Surg Am. 2005; 87:1761–1768. 11. Echinger JK, McKenzie CS, Devine JG. Evaluation of pediatric lower extremity fractures managed with external fixation: outcomes in a deployed environment. Am J Orthop. 2012;41:15–19. 12. Schranz PJ, Gultekin C, Colton CL. External fixation of fractures in children. Injury. 1992;23:80–82. 13. Bone LB, Sucato D, Stegemann PM, et al. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of control. J Bone Joint Surg Am. 1997;79:1336–1341. 14. Valverde S, Soleto J, Rodriguez-Durantez JA, et al. Premature physeal closure after tibial diaphyseal fractures in adolescents. J Pediatr Orthop. 2000;20:193–196. 15. Shannak AO. Tibial fractures in children: follow-up study. J Pediatr Orthop. 1988;8:306–310. 16. Dwyer AJ, John B, Krishen M, et al. Remodeling of tibial fractures in children younger than 12 years. Orthopaedics. 2007;30:393–396. 17. Goodwin RC, Gaynor T, Mahar A, et al. Intramedullary flexible nail fixation of unstable pediatric tibial diaphyseal fractures. J Pediatr Orthop. 2005;25:570–576. 18. O’Brien T, Wiesman DS, Ronchettii P, et al. Flexible titanium nailing for the treatment of the unstable pediatric tibial fracture. J Pediatr Orthop. 2004;24:601–609. 19. Yang JP, Letts RM. Isolated fractures of the tibia with intact fibula in children: a review of 85 patients. J Pediatr Orthop. 1997;17: 347–351. 20. Briggs TW, Orr MM, Lightowler CD. Isolated tibia fractures in children. Injury. 1992;23:308–310. 21. Gordon JE, Gregush RV, Shoenecker PL, et al. Complications after titanium elastic nailing of pediatric tibial fractures. J Pediatr Orthop. 2007;27:442–446. 22. Karladani AH, Granhed H, Edshage B, et al. Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients. Acta Orthop Scand. 2000;71:160–167.
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Displaced Tibial Shaft Fractures With Intact Fibula in Children: Nonoperative Management Versus Operative Treatment With Elastic Stable Intramedullary Nailing Federico Canavese, MD, PhD,* Alexei Botnari, MD,* Antonio Andreacchio, MD,w Lorenza Marengo, MD,w Antoine Samba, MD,* Alain Dimeglio, MD,z Bruno Pereira, PhD,y Mounira Mansour, MD,* and Marie Rousset, MD*
Background: The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced tibial shaft fractures with intact fibula in children after nonoperative management and operative treatment by elastic stable intramedullary nailing. Methods: A study was performed on 80 consecutive children, 56 males, 24 females from 2 Institutions, with displaced and closed tibial shaft fracture with intact fibula. All patients underwent regular clinical and radiographic follow-up visits for at least 2 years after injury. Results: In total, 26 patients (group A-Institution I) were treated surgically by elastic stable intramedullary nailing and 54 patients (18 patients from group B-Institution I and 36 patients from group C-Institution II) were treated nonoperatively with closed reduction and casting. groups A, B, and C did not significantly differ on sex (P = 0.37), side (P = 0.54), and fracture site (P = 0.14). Valgus deformity was significantly controlled in group A patients only (P = 0.001); during follow-up in group B patients (P = 0.017), and showed no significant change between pretreatment images and last follow-up in group C patients (P = 0.71). Procurvatum deformity was significantly controlled in group A patients only (P = 0.001); it showed no significant improvement after conservative treatment in group B (P = 0.73) and C patients (P = 0.8). Recurvatum was significantly improved in group A (P < 0.001) and C patients (P < 0.001) but remained unchanged in group B patients (P = 0.15). Varus deformity improved significantly in all patient groups. Immobilization time was significantly shorter in group A compared with group B and C patients (P < 0.001). However, numerical differences, although statistically significant, were not clinically relevant for all variables but immobilization time.
From the *Pediatric Orthopedic Department, Estaing University Hospital; yBiostatistics Unit, DRCI, Estaing University Hospital, Clermont-Ferrand; zFaculty of Medicine, Montpellier University, Montpellier, France; and wPediatric Orthopedic Department, Regina Margherita Children’s Hospital, Turin, Italy. None of the authors received financial support for this study. The authors declare no conflicts of interest. Reprints: Federico Canavese, MD, PhD, Pediatric Orthopedic Department, Estaing University Hospital, 1, Place Lucie et Raymond Aubrac, Clermont-Ferrand 63003, France. E-mail: canavese_ [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Conclusions: This study showed good functional and radiologic outcomes in the pediatric population who had sustained closed, traumatic, displaced fracture of tibial diaphysis without associated fibula fracture. On the basis of the findings reported here, it is not contraindicated to operate skeletally immature patients with displaced fracture of tibial diaphysis without associated fibula fracture. However, results were essentially the same and either method is a satisfactory choice for pediatric tibia shaft fractures with an intact fibula. In particular, we found that conservative treatment was as efficacious as surgical treatment apart from the length of time for immobilization. Level of Evidence: Level III. Key Words: tibia fracture, children, isolated, conservative, elastic stable intramedullary nailing (J Pediatr Orthop 2015;00:000–000)
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solated tibial shaft fractures in children are relatively common. In the pediatric population, isolated tibial shaft fractures account for about 75% of all tibia fractures and are associated with fibula fracture in about onethird of cases.1–5 Closed reduction and above-knee casting is the mainstay of treatment for isolated tibial shaft fractures.1,2,6 However, Gordon and O’Donnell7 reported that a relative indication for surgical stabilization in children with tibial fracture includes an intact fibula. Surgical treatment options include elastic stable intramedullary nailing (ESIN),4,8–10 Kirschner wire fixation,3 external fixation,10–12 and locked intramedullary nail fixation in patients with closed physis.13 ESIN has recently emerged as a safe and efficient method for the treatment of displaced long bone fractures, including tibial shaft fractures.4,8–10 ESIN provides stable fixation, good rotational stability, and relatively easy insertion and removal.4 However, although the ESIN technique as described by Ligier et al8 is minimally invasive, easy to learn, and has a low complication rate,7 tibial shaft fractures can prove problematic due to the tendency to displace.13–15 Tibial shaft fractures can be managed nonoperatively by closed reduction and casting or operatively by ESIN. Although both management options are widely
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used, there has been no published comparison of the outcomes of isolated tibial shaft fractures treated conservatively versus with ESIN. Dwyer et al16 have investigated the tolerance of malunion in pediatric tibial fractures and concluded that 10 degrees of varus, 8 degrees of valgus, up to 12 degrees of procurvatum, and 6 degrees of recurvatum are acceptable. However, it is still unclear whether surgical stabilization by ESIN is indicated in certain cases, due to the tendency of such injuries to displace.7,13–16 The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced tibial shaft fractures with intact fibula in children after nonoperative management and operative treatment by ESIN. We retrospectively reviewed our experience with these 2 techniques to determine whether 1 approach emerged as superior.
METHODS The study was performed on 80 consecutive pediatric case, 56 males, 24 females from 2 Institutions, who had displaced and closed tibial shaft fracture with intact fibula to evaluate the effect of type of treatment on clinical and radiologic outcome. Retrospective chart and radiograph review was carried out on all cases of skeletally immature patients with displaced and closed tibial shaft fracture with intact fibula referred to 2 institutions from September 2010 to 2012. All patients underwent regular clinical and radiographic follow-up for at least 2 years after injury. At each follow-up visit, full-length anteroposterior and lateral radiographs were taken of the affected leg to assess ongoing tibia fracture consolidation and detect complications such as secondary displacement, refracture, hardware migration, nonunion, or malunion. Complete fracture healing was defined as a full return to activities of daily living and sports. The study was approved was the Institutional Review Boards of each medical center.
Patients Demographics Chart and radiograph reviews were held on all patients to collect and compile personal and medical history data, that is, sex, age at time of trauma, mechanism of accident, side involved, existence of neurovascular insult, and concomitant diagnoses and treatment. Inclusion criteria were age 15 years old and below, presence of growth plate visible on plain radiographs, radiologically proven tibial shaft fracture without concomitant fibula fracture, and without neurovascular injury. Exclusion criteria were absence of growth plate visible on plain radiographs at the time of injury, tibial shaft fracture associated with fibula fracture, polytraumatized patients presenting with other associated fractures, and/or dislocations.
Treatment: Institution I Patients from the first institution were either treated operatively by ESIN (group A) or by nonoperative
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management (group B). Patients that were operated upon had fractures more displaced initially. Each procedure was performed by the same surgical team. Surgery was performed under general anesthesia with the patient placed supine on the operating table. Fracture was first reduced by closed manipulations under fluoroscopic control, then 2 same-diameter intramedullary elastic nails (Synthes, Etupes, France) were introduced through a 0.5 to 1 cm incision just below the proximal tibia growth plate at the proximal tibial metaphysis. The nails were then advanced beyond the fracture site.4,8–10 A layered wound closure was performed, leaving approximately 1 cm of each nail remaining outside the bone. After surgery, all patients were immobilized in a posterior long leg splint for a period of 3 to 4 weeks. Nonoperative management consisted of closed reduction under sedation and immobilization in an aboveknee cast for 6 weeks followed by short leg cast for a further 6 weeks.
Treatment: Institution II All patients from the second institution (group C) were treated by a conservative approach to isolated tibial shaft fractures involving closed reduction under sedation and immobilization in an above-knee cast for 6 weeks followed by short leg cast for a further 6 weeks. All procedures were performed by the same surgical team.
Radiographic Evaluation All patients underwent full-length anteroposterior and lateral radiographs of the injured leg. The tibial shaft is the area of bone below and above the proximal and distal tibia metaphysis, respectively. Only fractures that occurred in this area and managed either operatively by ESIN or nonoperatively by casting were included (Figs. 1, 2). Using the anteroposterior radiographs, fractures were classified as transverse, oblique, or spiroid on the basis of the relationship between the fracture line and the axis of the tibial shaft. When 3 or more fracture fragments were present, the fracture was classified as comminuted. Anteroposterior radiographs were used to assess varus or valgus deformity according to distal fragment displacement in relation to the axis of the tibial shaft. Lateral radiographs were used to assess degree of recurvatum or procurvatum angulation. Recurvatum is defined as a backward thrust of the angle between the axis of the proximal and distal fragments of the fracture. Procurvatum is the opposite. Radiographs of both Institutions were collected and analyzed by the senior author of this paper. Considering the standardized way of measuring 1 plane angulation on anteroposterior and lateral leg radiographs, no intraobserver and interobserver assessment was made. Moreover, according to our study protocol and our biostatistician’s advice, to avoid intraobserver and interobserver errors, we agreed to have all radiographs reviewed and measured by a single, experienced, rater (pediatric orthopaedic surgeon). Copyright
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Displaced Tibial Shaft Fractures
FIGURE 1. Conservative treatment. Left tibia spiroid fracture in a 8-year-old boy at the time of trauma (A, B) and at 9 months’ follow-up (C, D).
Statistical Analysis Statistical analyses were performed using Stata 13 software (StataCorp LP, College Station, TX). Tests were 2-sided, with a type-I error set at a = 0.05. Patient characteristics were presented as means (± SD) or medians (interquartile range) for continuous data (assumption of normality assessed using the Shapiro-Wilk test) and as number of patients and associated percentages for categorical parameters. Comparisons between independent groups were performed using w2 or Fisher’s exact tests for
categorical variables and using ANOVA or KruskalWallis tests as appropriate (homoscedasticity verified using Bartlett’s test) for quantitative parameters. To study the evolution of correlated repeated data, statistical analyses were performed using mixed models to evaluate fixed-effects group, time-points, and their interactions as fixed effects and to take into account between and withinpatient variability as random effects. Residual normality was checked. According to results observed concerning patient’s age in univariate analysis, an adjustment was
FIGURE 2. Surgical treatment. Right tibia transverse fracture in a 11-year-old boy at the time of trauma (A, B) and at 10 months’ follow-up, after hardware removal (C, D). Copyright
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proposed with this parameter as covariable in previous models. A sensitivity analysis was carried out to study the attrition bias and to characterize the statistical nature of missing data.
RESULTS Across the 2 institutions, 80 children (56 males, 24 females) with displaced and closed fracture of the tibial shaft with intact fibula were identified through charts and radiographic review and met the inclusion criteria.
Patients Demographics Table 1 recaps the demographic data collected. In total, 26 patients from Institution I (group A; 32.5%) were treated surgically by ESIN, whereas 18 patients from Institution I (group B; 22.5%) and 36 patients from Institution II (group C; 45%) were treated nonoperatively with closed reduction and casting. Groups A, B, and C did not significantly differ on sex (P = 0.37), side (P = 0.54), and fracture site (P = 0.14). In addition, groups B and C were comparable on treatment options (Table 1).
Radiologic Outcome Table 1 outlines the preoperative and postoperative isolated tibia fracture characteristics and amount of displacement on anteroposterior and lateral radiographs.
Varus Varus deformity improved significantly in all groups regardless of whether treatment was surgical (P < 0.001) or conservative (P = 0.006 for group B and P < 0.001 for group C). These results were confirmed by significant interaction time group obtained using random-effects model adjusted on age covariable (P < 0.001).
Valgus Valgus deformity was significantly controlled in operated patients (group A) only (P = 0.001). Valgus deformity worsened significantly during follow-up in group B patients (P = 0.017) and showed no significant change between pretreatment images and last follow-up in group C patients (P = 0.71). These results were confirmed by significant interaction time group obtained using randomeffects model adjusted on age covariable (P = 0.007).
Recurvatum Recurvatum improved significantly in group A (P < 0.001) and group C patients (P < 0.001) but remained unchanged in group B patients (P = 0.15). These results were confirmed by significant interaction time group obtained using random-effects model adjusted on age covariable (P < 0.001).
Procurvatum Procurvatum deformity was significantly controlled in operated patients (group A) only (P = 0.001). Procurvatum deformity showed no significant improvement after conservative treatment in group B patients (P = 0.73) and group C patients (P = 0.8). These results were confirmed by significant interaction time group
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obtained using random-effects model adjusted on age covariable (P < 0.001).
Treatment and Immobilization All group A patients were treated with 2 same-diameter elastic nails, ranging from 2 to 4 mm. The operated limb was placed in long-leg posterior splint for 6.6 ± 3.2 weeks. Group B and group C patients undergoing conservative treatment were immobilized in a long-leg cast for 10.9 ± 1.9 and 10 ± 1.5 weeks, respectively. Immobilization time was significantly shorter in group A compared with groups B and C (P < 0.001).
Functional Outcome At last follow-up visit, all patients had returned to previous daily and sport activities without discomfort or difficulty, and range of motion of the injured lower extremity was comparable with that of the contralateral side.
Complications One fracture displaced during orthopaedic treatment (group B) and needed closed reduction and ESIN stabilization under general anesthesia. The fracture eventually healed without any further complication. No other complications were observed in any of the 3 groups.
DISCUSSION Several recent papers support surgical stabilization of closed displaced pediatric fractures of the tibial diaphysis. Surgery is advocated due to fracture pattern instability and failure to maintain reduction in cases treated by cast.1,3,17,18 However, closed reduction and above-knee casting remains the mainstay of treatment for isolated tibial shaft fractures at most institutions.1,2,6 No study to date has compared outcomes in a homogenous case series of skeletally immature patients with displaced and closed tibial shaft fracture with intact fibula between those managed conservatively with closed reduction and casting and those operated by ESIN. This study included 2 groups of skeletally immature patients treated either conservatively or surgically. The 2 groups were homogenous. We found that both procedures have equally clinically acceptable results, with the same rate of additional procedures required and the same amount of angulatory deformity at final follow-up (Table 1). Isolated tibial shaft fractures in children are common lower extremity fractures that can be problematic in certain cases. Yang and Letts19 reviewed 95 cases of isolated tibial shaft fractures in children and highlighted that when displaced, diaphyseal tibial fracture with intact fibula can be difficult to reduce. Moreover, reduction can be difficult to hold in position because of the splinting of the intact fibula. In particular, the intact fibula, acting as a splint, is responsible for varus angulation. Yang and Letts19 suggested close monitoring with weekly anteroposterior and lateral leg radiographs for the first 3 weeks postcast. Moreover, Gordon and O’Donnell7 Copyright
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Displaced Tibial Shaft Fractures
TABLE 1. Patient Demographics and Fracture Characteristics Total (n = 80) Sex, males [n (%)] 56 (70) Age at injury (mean ± SD) (y) 9 ± 3.3 Type of fracture [n (%)] Comminutive 3 (3.8) Spiroid 60 (75.0) Oblique 11 (13.7) Transverse 6 (7.5) Side [n (%)] Right 40 (50) Postoperative immobilization Weeks (mean ± SD) — Preoperative translation (mean ± SD) (%) AP view — LL view — Preoperative angulation (mean ± SD) (deg.) Valgus — Varus — Recurvatum — Procurvatum — Postoperative angulation (mean ± SD) (deg.) Valgus — Varus — Recurvatum — Procurvatum — Final assessment (mean ± SD) (deg.) Valgus — Varus — Recurvatum — Procurvatum — Additional procedure 1 (1.2) [n (%)]
Group A (n = 26; 32.5%)
Group B (n = 18; 22.5%)
Group C (n = 36; 45%)
Groups B+C (n = 54; 67.5%)
17 (65.4) 11.1 ± 3.4
11 (61.1) 7.7 ± 3.7
28 (77.8) 8.2 ± 2.3
39 (72.2) 8.0 ± 2.8
2 (7.7) 15 (57.7) 5 (19.2) 4 (15.4)
0 (0.0) 13 (72.2) 5 (27.8) 0 (0.0)
1 32 1 2
(2.8) (88.8) (2.8) (5.6)
1 (1.9) 45 (83.3) 6 (11.1) 2 (3.7)
12 (46.1)
11 (61.1)
17 (47.2)
28 (51.9)
6.6 ± 3.2
10.9 ± 1.9
10 ± 1.5
10.3 ± 1.7
23 ± 21.7 18.8 ± 15.1
5.1 ± 2.3 5.6 ± 1.7
20.8 ± 13.8 20.2 ± 11.3
13 ± 8.1 12.9 ± 6.5
1.81 ± 2.83 2.69 ± 4.42 3.58 ± 3.95 1.02 ± 1.61
0.33 ± 0.59 2.06 ± 3.46 1.78 ± 2.29 0.50 ± 1.25
0.26 ± 0.79 0.85 ± 1.49 0.82 ± 0.96 0.11 ± 0.52
0.29 ± 0.72 1.25 ± 2.37 1.14 ± 1.58 0.24 ± 0.85
0.61 ± 1.36 0.13 ± 0.69 0.19 ± 0.69 0.00 ± 0.00
2.72 ± 3.10 0.39 ± 0.61 1.22 ± 1.66 0.56 ± 1.34
0.56 ± 1.69 2.67 ± 2.44 0.15 ± 0.52 0.09 ± 0.41
1.28 ± 2.45 1.91 ± 2.29 0.51 ± 1.15 0.25 ± 0.86
0.23 ± 0.59 0.08 ± 0.27 0.69 ± 1.09 0.00 ± 0.00 0
1.78 ± 2.04 0.22 ± 0.55 1.11 ± 1.81 0.39 ± 1.20 1 (1.9)
0.33 ± 0.96 2.76 ± 2.22 1.88 ± 1.57 0.14 ± 0.63
0.81 ± 0.23 1.92 ± 2.19 1.62 ± 1.68 0.22 ± 0.86
Group A: surgical treatment; Group B: conservative treatment, Institution I; Group C: conservative treatment, Institution II. AP indicates anteroposterior; LL, lateral.
reported that relative indications for surgical stabilization include displaced tibia fractures with an intact fibula. Shannak’s15 review of 117 patients with leg fracture found that only 27% (32/117 patients) had isolated tibial diaphyseal fractures, and that about a third of patients with more than 10 degrees of angulation at consolidation did not fully remodel at 3- to 10-year follow-up. Shannak15 also highlighted that in skeletally immature patients, varus deformities can undergo spontaneous correction, whereas valgus deformity and recurvatum, as well as rotational deformities, tend to persist. Dwyer and colleagues reviewed 48 patients below 12 years of age and investigated the tolerance of malunion in such injuries. They found that procurvatum deformity realigned maximally (52.7%), followed by varus (40.9%), valgus (23.9%), and recurvatum (18.5%). They concluded that 10 degrees of varus, 8 degrees of valgus, up to 12 degrees of procurvatum, and 6 degrees of recurvatum are acceptable.16 Here, we did not record any significant valgus and procurvatum remodeling in conservatively treated patients. Moreover, 33.3% of patients conservatively treated showed no significant improvement of recurvatum deformity. Briggs et al20 reviewed a series of 25 cases of displaced isolated tibial shaft fractures in which these injuries represented Copyright
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about a third of all tibial fractures in children aged under 11 years (25/65 patients). They found that secondary displacement can occur during the first 2 to 3 weeks postcast and recommended repeated closed reduction and casting if varus displacement exceeds 5 degrees. Manipulations after that period will fail due to progressive fracture consolidation.20 Here, residual deformity on both frontal (valgus) and coronal planes (procurvatum; recurvatum in 33.3% of conservatively treated patients) occurred only in patients treated by closed reduction and casting. Operated patients showed no sign of secondary displacement in any of the 3 planes of space. Furthermore, operated patients had significantly shorter immobilization time compared with conservatively treated patients (Table 1). The reported rate of failure of cast treatment in isolated diaphyseal tibial fractures leading to unplanned surgical procedure varies between 2% and 5%.7,15,19,20 In our series, 1 of 54 fractures treated conservatively (1.9%) displaced during orthopaedic treatment (group B) and needed closed reduction and ESIN stabilization under general anesthesia. The fracture eventually healed without any further complication. Although we did not observe any complication in surgically treated patients, surgical stabilization by ESIN
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is not free of potential complications. Gordon et al21 observed several complications in their retrospective review of 60 diaphyseal tibia fractures (31 closed and 29 open fractures) treated with ESIN. They reported delayed union in 5 cases (8.3%), malunion in 1 case (1.7%), osteomyelitis in 1 case (1.7%), and nail migration in 2 cases (3.5%). Gordon et al21 concluded that fixation of pediatric diaphyseal fractures with ESIN is effective but complications can arise, particularly in older patients. Similarly, Mashru et al1 and Goodwin et al17 reported significant complications such as nail migration, nonunion, malunion, and compartment syndrome. In our group of patients, the overall rate of complications in ESIN-treated patients was low compared with previously published data. We reviewed a homogenous case series of skeletally immature patients with displaced, isolated, and closed tibial shaft fracture. No open fractures were included. Type of fracture and amount of displacement may thus have led to a lower rate of complications in this patient population. Studies have compared surgical versus conservative management for isolated diaphyseal fractures in adults and found similar results to those reported in children. Bone et al13 conducted an outcome analysis of matched pairs of adult patients and concluded that treating isolated, displaced, and closed fractures of the tibial shaft with closed intramedullary nailing with reaming provides superior functional outcomes compared with casting. Similar findings were later published by Karladani et al.22 On the basis of the findings reported here, it is not contraindicated to operate skeletally immature patients with displaced fracture of tibial diaphysis without associated fibula fracture. However, results were essentially the same and either method is a satisfactory choice for pediatric tibia shaft fractures with an intact fibula. This study showed good functional and radiologic outcomes in the pediatric population who had sustained closed, traumatic, displaced fracture of tibial diaphysis without associated fibula fracture. In particular, we found that conservative treatment was as efficacious as surgical treatment apart from the length of time for immobilization. REFERENCES 1. Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. J Am Acad Orthop Surg. 2005;13: 345–352.
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2. Setter KJ, Palomino KD. Pediatric tibia fracture: current concepts. Curr Opin Pediatr. 2006;18:30–35. 3. Qidawi SA. Intramedullary Kirschner wiring for tibia fractures in children. J Pediatr Orthop. 2011;21:294–297. 4. Srivastava AK, Mehlman CT, Wall EJ, et al. Elastic stable intramedullary nailing of tibial shaft fractures in children. J Pediatr Orthop. 2008;28:152–158. 5. Rodriguez-Merchan CE. Pediatric skeletal trauma: a review and historical perspective. Clin Orthop Rel Res. 2005;432:8–13. 6. Sarmiento A, Sharpe FE, Ebramzadeh E, et al. Factors influencing the outcome of closed tibial fractures treated with functional bracing. Clin Orthop Rel Res. 1995;315:8–24. 7. Gordon JE, O’Donnell J. Tibia fracture: what should be fixed? J Pediatr Orthop. 2012;32:S52–S61. 8. Ligier JN, Me´taizeau JP, Pre´vot J. Closed flexible medullary nailing in pediatric traumatololgy. Chir Pediatr. 1983;24:383–385. 9. Me´taizeau J. Oste´osynthe`se chez l’enfant: embrochage centrome´dullaire e´lastique, stable. Montpellier, France: Sauramps Me´dical; 1988. 10. Kubiak EN, Egol KA, Scher D, et al. Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation? J Bone Joint Surg Am. 2005; 87:1761–1768. 11. Echinger JK, McKenzie CS, Devine JG. Evaluation of pediatric lower extremity fractures managed with external fixation: outcomes in a deployed environment. Am J Orthop. 2012;41:15–19. 12. Schranz PJ, Gultekin C, Colton CL. External fixation of fractures in children. Injury. 1992;23:80–82. 13. Bone LB, Sucato D, Stegemann PM, et al. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of control. J Bone Joint Surg Am. 1997;79:1336–1341. 14. Valverde S, Soleto J, Rodriguez-Durantez JA, et al. Premature physeal closure after tibial diaphyseal fractures in adolescents. J Pediatr Orthop. 2000;20:193–196. 15. Shannak AO. Tibial fractures in children: follow-up study. J Pediatr Orthop. 1988;8:306–310. 16. Dwyer AJ, John B, Krishen M, et al. Remodeling of tibial fractures in children younger than 12 years. Orthopaedics. 2007;30:393–396. 17. Goodwin RC, Gaynor T, Mahar A, et al. Intramedullary flexible nail fixation of unstable pediatric tibial diaphyseal fractures. J Pediatr Orthop. 2005;25:570–576. 18. O’Brien T, Wiesman DS, Ronchettii P, et al. Flexible titanium nailing for the treatment of the unstable pediatric tibial fracture. J Pediatr Orthop. 2004;24:601–609. 19. Yang JP, Letts RM. Isolated fractures of the tibia with intact fibula in children: a review of 85 patients. J Pediatr Orthop. 1997;17: 347–351. 20. Briggs TW, Orr MM, Lightowler CD. Isolated tibia fractures in children. Injury. 1992;23:308–310. 21. Gordon JE, Gregush RV, Shoenecker PL, et al. Complications after titanium elastic nailing of pediatric tibial fractures. J Pediatr Orthop. 2007;27:442–446. 22. Karladani AH, Granhed H, Edshage B, et al. Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients. Acta Orthop Scand. 2000;71:160–167.
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