ER: A Shift in the Night

each post gonna contain a bunch of cases i visited on ER or Clinic a week before

Monday, April 20, 2009

Pediatric Tibial Fracture

- Shortening: 
    - pediatric tibial frxs do not have much potential for overgrowth, hence, it is essential to to maintain frx out to length; 
    - when shaft of tibia & fibula are fractured, major problem, is shortening; 
           - w/ fibula no longer intact, long flexor muscles tend to produce a valgus deformtiy at the fracture site; 
    - acceptable shortening: 
           - 1 to  5 yrs of age: 5 - 10 mm 
           - 5 to 10 yrs of age: 0 -  5 mm 

- Axial Malalignment: 
       - frxs of tibia and fibula do not have much poential to correct axial malalignment; 
       - acceptable reduction: 
            - less than 10 deg of recurvatum; 
            - less than 5 deg of varus or valgus angulation; 

- Treatment: 
    - cast application
            - frx of tibial & fibular shafts in children are usually uncomplicated and can be treated by closed reduction and long leg cast application; 
            - flexion to 45 deg will facilitate rotational control of the fracture; 
            - w/ a recurvatum deformity, the foot should be placed in slight plantar-flexion: neutral dorsiflexion will increase frx recurvatum in an unstable frx; 
            - in older children, the long leg cast can be converted to a patellar tendon bearing cast after a period of 3 weeks; 
    - intramedullary nails: (synthes technique manual)
            - references: 
                   - Intramedullary Kirschner wiring for tibia fractures in children. 
                   - Operative Treatment of Tibial Fractures in Children: Are Elastic Stable Intramedullary Nails an Improvement Over External Fixation? 
                   - Intramedullary Flexible Nail Fixation of Unstable Pediatric Tibial Diaphyseal Fractures. 
    - external fixation: 
            - External fixation of lower limb fractures in children. 

- Varus Mal-Reduction: 
      - oblique isolated frx of tibial shaft (w/ fibula intact) may drift into varus because of pull of long flexors of the toes & ankle; 
      - varus mal-reduction is addressed by placing knee in flexion & ankle in mild plantar flexion during first 1-2 weeks of immobilization; 

Original Text by Clifford R. Wheeless, III, MD.



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