Some Lower Leg Fractures Must Have Surgery

Fractures of the lower leg (tibia) are most often treated with cast immobilization. But when the fracture is unstable and especially if the bone is broken in multiple places, then surgery may be needed. The authors of this article reviewed the published literature looking for information on the surgical treatment of tibial fractures in children. They provide their findings and their own opinions based on clinical experience.

Any bone fracture near a joint in a child raises concerns and issues about growth. Consideration is always given to the effect of the injury and any treatment planned on bone growth. The goal of surgery is to stabilize the bone and maintain good alignment and length.

In the case of tibial shaft fractures (the shaft is the long part of the bone), compartment syndrome is a second very real concern. Compartment syndrome describes a condition in which fluid (swelling or blood) builds up inside one or more of the individual compartments of the leg. Traumatic injuries, especially bone fractures that puncture the soft tissues are a common cause of compartment syndrome.

Surgical treatment usually follows one of two approaches: the use of titanium elastic nails or external circular fixation. Titanium elastic nails are somewhat flexible but sturdy, thin rods that are inserted into the center of the bone to support and align it while healing. The surgeon must be careful when placing the rods not to disrupt the growth plate. The authors provide some details in their recommendations for nail placement that might be of interest to other surgeons using this treatment technique.

External circular fixation is just as the name describes — a metal cage that encircles the lower leg on the outside. Pins placed horizontally from the cage through the leg hold everything together and even allow the child to put weight on the leg. Weight-bearing and walking on the surgical side isn’t advised until X-rays show good alignment and signs of bone healing. This usually takes about three weeks in children and teens.

After surgery, the leg is placed in a splint to help prevent motion at the fracture site and nonunion or malunion. The child is monitored for any postoperative complications, especially compartment syndrome. Pain out of proportion to the injury, pain that isn’t relieved by medications, and increased use of pain medication (e.g., narcotics) are early signs of a potential problem.

Anyone experiencing numbness or partial paralysis must see a physician right away. The surgeon will remove anything from around the leg (cast, splint) and take the pressure off the leg. There isn’t a fool-proof test for compartment syndrome.

Failure to relieve pain by removing external pressure on the leg means surgery is needed. A fasciotomy is done immediately. In this procedure, the surgeon cuts through the fascia or connective tissue around the muscles of the leg forming four distinct compartments. The purpose is to take pressure off the tissues and restore normal circulation to the leg, thus avoiding the need for amputation.

In summary, fractures of the tibial shaft are common injuries among children. Treatment can be straight forward with cast immobilization but the surgeon must evaluate each child and assess for the need to do surgery. Fractures most likely to need surgery are unstable, poorly aligned or separated, open, and/or with many broken pieces.

Nonunion or malunion can still occur even with fixation (hardware such as rods inside the shaft of the bone or an external circular cage). Serial X-rays are needed to see if and how well the fracture(s) is/are healing. Failure to achieve acceptable alignment in an acceptable or reasonable amount of time may result in the child needing serial (multiple) surgeries. The child must be observed carefully throughout the healing time for any signs of compartment syndrome. Failure to treat compartment syndrome immediately can result in loss of circulation to the leg (ischemia with a potential to lose the leg.