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Pediatric tibial shaft fractures: the relation between external and internal fixation

Tibial shaft fractures are mostly due to falls during recreational activities. They can be treated conservatively by cast immobilization with excellent outcomes, including four to six weeks of long leg cast followed by a short leg cast or a removable fracture boot.

However, there are cases where operative interventions are essential. For example,when the injury mechanism is secondary and involves a direct impact that leads to a skin injury, with or without exposure of the fracture, a compartment syndrome or an unstable and displaced fracture. Treatment must provide a correct reduction and stability, allowing the control wound healing. There are two main surgical techniques that have been reported as an effective way to treat tibial shaft fractures in children:

– Internal fixation (elastic nails and screws);

– External fixation.

Internal fixation is a great option, however is not stable enough to be used alone and it requires supplemental long leg cast application and that is why elastic stable intramedullary nailing (ESIN) has been commonly used. It provides stability, flexible mobility and is usually performed by closed reduction.

External fixations have been recommended for unstable patterns with associated injuries, like open fractures, compartment syndrome and polytraumatisme, but several complications have also been frequently reported, such as nonunion; delayed union; malunion; pin infections and re-fracture.

ESIN might be the most common technique used for surgical treatment of diaphyseal long bones fractures, tibial shaft fractures showed a higher rate of complications than femoral shaft fractures. Monolateral external fixation was reported to be a simple and effective procedure in the treatment of displaced tibial fractures in children. Risks of pin infection, nonunion, loss of reduction and re-fracture have cool down with their use.


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