Session V - Knee / Tibia / Pediatrics

Fri., 10/15/10 Knee, Tibia & Pediatrics, Paper #61, 4:27 pm OTA-2010

Isolated Pediatric Tibial Shaft Fractures Do Not Need to be Treated in Above-Knee Cast

Joshua W.B. Klatt, MD; Alan K. Stotts, MD; John T. Smith, MD
University of Utah, Primary Children’s Medical Center, Salt Lake City, Utah, USA

Purpose: The gold standard for conservative management of closed tibial shaft fractures in children, whether isolated or with associated fibula fracture, historically has been an above-knee cast (AKC), transitioned to a below-knee cast (BKC) after 2 to 4 weeks. The purpose of this study was to evaluate the effectiveness of using an immediate BKC for pediatric tibia fractures without fibula fracture by reviewing a large cohort of patients treated in this manner.

Methods: A retrospective analysis was performed reviewing all the isolated tibia fractures treated at a Level 1 pediatric trauma center over a 4-year period (2003-2006). The medical records and radiographs of 332 children were reviewed. Those patients treated only with a BKC were compared to a cohort of those treated initially with an AKC, examining differences in rates of malunion and complications. Choice of treatment was at surgeon discretion.

Results: Of the 332 children with isolated tibial shaft fracture, 47 were initially treated elsewhere. Seven fractures were treated operatively, and nine had either inadequate follow-up or were treated definitively in splints or fracture boots, leaving 269 patients for final review. 225 were treated in a BKC and 44 were treated in an AKC. Age ranged from 6 months to 15 years, with a mean of 5.1 years. There were 186 boys and 83 girls. 132 patients had left tibia fractures, 136 had right tibia fractures, and 1 patient had bilateral fractures. Two patients had compartment syndrome treated with fasciotomy, subsequently treated in BKCs. One BKC patient had a partial-thickness skin ulcer, with none in the AKC group. All fractures healed. There was one refracture in the AKC group (2%) and three refractures in the BKC group (1.3%). Refractures occurred at a mean of 7 weeks (range, 6-8 weeks) after cast removal. In the AKC group, the average presenting angulation was 2.0° (range, 0°-8°) in the coronal plane and 0.8° (range, 0°-12°) in the sagittal plane. Final angulation was 2.1° coronal (range, 0°-10°) and 2.5° sagittal (range, 0°-9°). In the BKC group, the average presenting angulation was 0.9° (range, 0°-9°) in the coronal plane and 1.8° (range, 0°-7°) in the sagittal plane. Final angulation was 3.4° coronal (range, 0°-10°) and 1.1° sagittal (range, 0°-12°). There were 2 BKC patients (0.9%) and 1 AKC patient (2.3%) with postcast coronal angulation ≥10°. There were 7 patients (3.1%) in the BKC group and 6 (13.6%) in the AKC with postcast sagittal angulation ≥5°.

Conclusion: In this retrospective cohort study, below-knee casting for isolated pediatric tibial shaft fractures without fibula fracture appears to be equally effective to above-knee casting. There was no significant increase in the risk of malunion or refracture with this form of treatment. This study supports that below-knee casting for isolated tibial shaft fractures is a safe and effective alternative to above-knee casting in children.

Alphabetical Disclosure Listing (292K PDF)

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.