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Update on leg fractures in paediatric patientsJean-Damien Metaizeau, Delphy Denis

To cite this version:Jean-Damien Metaizeau, Delphy Denis. Update on leg fractures in paediatric patients. Orthopaedics &Traumatology: Surgery & Research, Elsevier, 2019, 105, pp.S143 - S151. �10.1016/j.otsr.2018.02.011�.�hal-03484578�

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Review article

Update on Leg Fractures in Paediatric Patients

J.D. METAIZEAU 1, D. DENIS 1

1 Pediatric orthopedic department, university hospital F. Mitterrand, 21079 Dijon, FRANCE

Corresponding author: JD Métaizeau,

E-mail: jd.metaizeau@yahoo.fr

© 2018 published by Elsevier. This manuscript is made available under the CC BY NC user licensehttps://creativecommons.org/licenses/by-nc/4.0/

Version of Record: https://www.sciencedirect.com/science/article/pii/S1877056818300963Manuscript_01fa26c81e704132b7df8b8d3d843b60

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ABSTRACT

Leg fractures are common and further increasing in prevalence in paediatric patients. The

diagnosis is readily made in most cases. Choosing the best treatment is the main issue.

Non-operative treatment is the reference standard for non-displaced or reducible and stable

fractures but requires considerable expertise and close monitoring, as well as an

immobilisation period that far exceeds 3 months in many cases. Some surgical teams

therefore offer elastic stable intramedullary nailing (ESIN) as an alternative to children who

do not want to be immobilised for several months.

Internal fixation is required for unstable or irreducible leg fractures. ESIN is often used as the

first-line method, based on its very good risk/benefit ratio. For fractures that do not lend

themselves to ESIN, optimal stabilisation can be achieved by choosing among the other

available options (screw-plate fixation, rigid intra-medullary nailing, or external fixation) on

a case-by-case basis.

Close monitoring during the first few days is crucial to ensure the early detection of

compartment syndrome. The other complications and sequelae are non-specific.

Key words: Fracture. Paediatrics. Elastic nailing. Leg.

3

INTRODUCTION

Leg fractures are common in paediatric patients, in third position by order of frequency

after forearm and femoral fractures. Background information on paediatric leg fractures is

dealt with only briefly here, as the 2005 instructional course lecture by B. De Courtivron

offers an excellent overview.[1] The present lecture focusses on the advantages and

drawbacks of each treatment option, therapeutic indications, post-operative management and

the prevention of known complications.

1 DIAGNOSIS AND MANAGEMENT

1.1 Diagnosis

By definition, leg fractures are located between two metaphyses, although secondary

fracture lines may involve the neighbouring joint. Consequently, fractures involving the

epiphyses or confined to the metaphyses are not discussed here.

The annual incidence of leg fractures has been estimated at about 1% in girls and 2% in

boys. The overall prevalence of paediatric leg fractures is on the rise.[2,3]

The main causes are traffic accidents, falls, direct impact, and sports injuries.

The diagnosis is readily made in most cases. Attention should be directed to the

possibility of a hairline fracture in a young child, which may be challenging to detect; a

pathological fracture at the site of an osteolytic lesion; battered child syndrome; and stress

fracture.

Compound fractures are not infrequent given the superficial location of the anterior

tibia.

4

The patient must be carefully examined for evidence of neurovascular injuries, other

fractures, and other types of lesions.

Antero-posterior and lateral radiographs of the leg including the knee and ankle should

be obtained.

Leg fractures can be classified based on fracture line direction (transverse, oblique,

spiral, butterfly, or comminuted) or location (proximal, middle, or distal third). In addition,

young children may experience incomplete fractures (greenstick fractures, torus fractures,

bowing fractures).

The most useful classification, however, distinguishes between stable fractures (tibia

only or both bones but with a transverse or short oblique fracture line) and unstable fractures

(spiral, long oblique, bifocal, with a third fragment, or with comminution of both bones).

1.2 Initial management

The standard measures should be taken: insertion of an intravenous line, administration

of potent analgesics (morphine if needed) and nitrous oxide, scrupulous wound cleansing

with antiseptics and prophylactic antibiotic therapy if the skin is breached, and

immobilisation by a posterior plaster splint. The importance of taking nothing by mouth

should be impressed on the patient and parents.

2 NON-OPERATIVE TREATMENT

The main advantage of non-operative treatment is non-invasiveness: as no material is

implanted, there is no scarring, and there is no risk of infection if the skin is intact.

Affordability is another asset.

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Drawbacks[4] include a long immobilisation period that can far exceed 3 months,

during which close clinical and radiological monitoring must be provided. A repeat reduction

manoeuvre is required in some cases. Importantly, considerable expertise is required to

fashion an optimal cast.

2.1 Fractures with little or no displacement

The plaster cast can be made at the emergency department, with analgesics and nitrous

oxide to ensure pain control.

A snug long-leg cast should be fashioned with two bandages and no cotton padding or

one bandage and very little cotton padding. The first layer must be made of plaster of Paris to

ensure tight moulding over the fracture. Resin may be added subsequently to decrease the

weight of the cast. Special care should be taken at sites where the skin is exposed to injury

(calcaneus, Achilles tendon, and head of the fibula). Some mechanisms of injury such as

high-energy trauma, direct impact, and crush injury carry a high risk of oedema, for which a

preventive measure is immediate splitting of the cast, a procedure performed routinely by

many surgical teams.

2.2 Displaced fractures

The fracture should be reduced in the operating theatre under general anaesthesia and

fluoroscopic guidance. An aide holds the thigh with the knee flexed at 90° and maintains the

foot by holding the toes. Another option consists in making the cast with the leg hanging over

the edge of the table.

If the fibula is intact (2/3 of cases), the application of forces in valgus and flexion to

correct the varus and recurvatum is sufficient to reduce the fracture. In contrast, when both

bones are fractured, the rotational displacement must also be corrected, by assessing the

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position of the malleoli relative to the patella with the knee flexed, as well as the loss of limb

length, which should ideally be kept below 10 mm. In the coronal plane, slight valgus is

needed (antero-lateral compartment), and in the sagittal plane the foot should be positioned in

slight equinus to relax the calf muscles.

A snug plaster boot is fashioned, and the corrective forces are then applied while the

plaster dries. Even distribution of the forces is important to avoid necrosis under the cast. If

the reduction is satisfactory, the plaster cast is extended up to the greater trochanter with the

knee in 30° to 50° of flexion.

When full control of all displacements is difficult to achieve and unacceptable

angulation persists, one option consists in waiting a few minutes for the plaster to harden then

wedging the cast.

2.3 Cast wedging

Cast wedging is an integral part of the non-operative treatment armamentarium. We

advocate open wedging to avoid the risks of limb shortening and skin impingement

associated with closed wedging. The exact site of the deformity should be marked, for

instance by taping a paper clip to the cast then obtaining a radiograph. The plane of the main

deformity is then assessed. The cast is cut circumferentially at the apex of the deformity,

perpendicularly to the axis of the leg, leaving only a 2- to 3-cm bridge over the apex of the

angulation. For instance, in the event of varus malalignment, a lateral bridge is left to allow

medial opening, thereby producing valgus realignment. The deformity is corrected by

opening the cast. We use pieces of cork or plastic that we cut to size and insert to hold the cut

open. A notch should be made to prevent wedge migration towards the skin. A layer of resin

is then added over the wedge. Accuracy is crucial to ensure a good outcome (Figure 1).

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Cast wedging is effective during the first 3 weeks, before the callus is substantially

calcified. Cast wedging is not appropriate to treat limb shortening, translation, or rotation

deformities. If the angulation exceeds 20°, the best strategy is to make a new cast.

2.4 Monitoring

After closed reduction in the operating theatre, the patient should be admitted for at

least one night to allow monitoring of the limb and to ensure the early detection of

compartment syndrome. Emphasis should be put on the importance of resting with the limb

slightly elevated during the first 72 hours after the patient is discharged home. The family

should be instructed about the signs that may indicate incipient compartment syndrome,

which require an immediate visit to the emergency department. Analgesics and anti-

inflammatory drugs should be prescribed, as well as anticoagulant therapy in post-pubertal

adolescents.

Ambulation with crutches is possible from about 7 years of age onwards but is often

difficult initially. Radiographs should be obtained after reduction then on days 15, 30, 45, and

90.[4]

The long-leg cast is usually replaced by a resin walking boot on day 30 or 45,

depending on the progression of fracture healing. Care should be taken to immobilise the

ankle at 90° of flexion. Weight bearing is then allowed.

2.5 Acceptable residual deformities

Natural remodelling occurs in children, spontaneously correcting certain angle

deformities. Factors associated with a greater potential for spontaneous correction include

younger age, location of the fracture near a growth plate, and deformity within the plane of

the motion range of the adjacent joint.

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In theory, correction is best for flexion and varus and worst for valgus and

recurvatum.[5,6] Cut-offs for acceptable residual angulations after reduction are difficult to

establish, as the range of natural correction varies with the above-listed factors. Another

factor may be pre-existing lower limb alignment. For instance, a patient with pre-existing

varus of the knee may be unable to tolerate any additional varus. Nevertheless, in girls

younger than 10 and boys younger than 12 years of age, the post-reduction deformity should

be kept below 10° of flexion or varus and 6° of valgus or recurvatum.[ 5,6] In older children,

no spontaneous correction is to be expected. Nevertheless, Sarmiento[7] stated that, in adults,

acceptable post-reduction deformities were 5° of angulation in the coronal and 10° in the

sagittal planes, up to 50% of translation, and up to 10 mm of limb shortening. Rotational

deformities do not correct spontaneously and must therefore receive very close attention

during the reduction.

Proximal fractures and isolated tibial fractures deserve special attention given the risk

of secondary valgus angulation, even in the absence of initial displacement. The parents must

be informed of this possibility. A waiting period of at least 2-3 years is recommended, as

spontaneous realignment of the underlying tibia is common. If realignment does not occur,

medial tibial epiphysiodesis appears to be a reasonable option.

3 SURGICAL TREATMENT

Several methods are available. Selection of the appropriate method is based on fracture

type and patient age.

3.1 Elastic stable intra-medullary nailing (ESIN)

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Technique: Elastic stable intra-medullary nailing (ESIN) is specifically intended for the

treatment of paediatric fractures. Although ESIN has been described in detail elsewhere,[8-10]

our experience has taught us that many crucial technical details are frequently overlooked,

leading to suboptimal outcomes. Consequently, instead of providing a full description of the

ESIN technique, we will emphasise specific points that we feel are of paramount importance.

The patient is supine. A pad may be placed under the knee to facilitate traction. We

find it useful to assess hip rotation and to place a pad either under the ipsilateral buttock to

induce internal rotation or under the contralateral buttock to induce external rotation. The

patient is thus in a three-quarter oblique position, so that slightly rotating the leg allows both

antero-posterior and lateral views to be obtained without moving the image intensifier.

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The nail diameter should be as large as possible, i.e., about 0.4 times the diameter of

the intramedullary canal measured on a radiograph at the isthmus. Special nails that are

flattened on one side ensure better filling of the canal. Importantly and in contradiction to

frequently expressed opinion, although the external tibial cross-section is triangular, the

tibial canal is round. Therefore, the standard ESIN technique applies (Figure 2). Steel is less

elastic than titanium but twice as strong at a given diameter. Steel nails are therefore

preferable in overweight children with unstable fractures.

Antegrade nailing is usually preferred, via two proximal entry points on either side of

the anterior tibial tuberosity, whose integrity must be preserved with the greatest care

(Figures 3 and 4). Alternatively, the nails may be inserted in the retrograde direction through

two entry points above the medial malleolus and at the lateral aspect of the tibia after

displacing the extensor muscles. During insertion, the second nail should not be rotated by

more than 180° in either direction, to avoid snagging the first nail. Before inserting the two

nails into the metaphysis, the rotational deformity should be corrected and the fracture

reduced as completely as possible by external manipulation ( Scenario A).

In theory, once the construct is complete, the two nails exert opposing forces, thereby

providing elastic stability. Nevertheless, the construct should be adapted to the forces

applied to the bone by the muscles and tendons. To this end, the direction of the nails should

be chosen carefully to ensure optimal reduction and stability. Before fully impacting the

nails into the bone, the quality of the reduction should be checked in all three planes, with

special attention to rotation. If any deformities persist, the appropriate corrections should be

made (Scenario B and C). As a result, the nails do not always diverge but may instead aim in

the same direction. An intact fibula creates a force in varus, whose counteraction usually

requires directing both nails towards the fibula (Figures 5 and 6). Importantly, the nail end

should not be bent at 90° before being cut, as this may result in major discomfort. The

11

elasticity of the nails (particularly those made of titanium) allows the end to be bent just

enough for the cut to be made a short distance under the skin. Once the nail is released, it

recoils until it contacts the bone. As a result, there is no discomfort to the patient, and the

length of the nail tip is sufficient to allow easy removal.

Advantages: low cost, early mobilisation, minimal scars, low risk of infection, and

preservation of the growth plates[11-16]

Drawbacks: specific training in the technique is required[13,17] and stabilisation is more

difficult to obtain in overweight children with unstable fractures.

3.2 Rigid intra-medullary nailing

Technique: Identical to that used in adults

Advantages: Early mobilisation and weight bearing, good correction of rotational

displacement, and excellent stability of the construct

Drawbacks: Suitable only for adolescents whose skeletal growth is nearly complete, as the

nail crosses the proximal tibial growth plate; possible increase in the risk of compartment

syndrome[18]

3.3 Screw-plate fixation

Technique: A simple plate may be used, although a locking plate provides better immediate

stability. The technique is the same as in adults. Appropriately sized material must be used

and care taken to preserve the growth plates when the diaphysis is fractured near the

proximal or distal joint (Figure 7). In theory, the plate can be positioned either medially or

laterally in children, given the good quality of the skin. Locking plates can be slipped into

the subcutaneous tissue to minimise the surgical approach.[19] To avoid specific

complications, the plates should be removed as soon as the fracture is healed.

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Advantages: Fluoroscopy is not always necessary when a direct approach is used, the

technique is simple and nearly always feasible, and the cost is moderate if non-locking plates

are used

Drawbacks: The direct approach to the fracture site increases the risk of infection, the scar is

longer, and subsequent lengthening may be more common. Re-fracture may occur, as stress

shielding results in thinning of the cortices. Removal of the material is associated with

specific morbidity.

3.4 External fixation

Technique: The techniques are the same as those used in adults. The size of the fixator and

pins must be appropriate for the size of the child and care should be taken not to damage the

growth plates. A unilateral or ring fixator may be used. The new generation hexapod ring

fixators equipped with software have the major advantage of ensuring faultless secondary

correction, thereby obviating the need for revision surgery.[20]

Advantages: External fixation is usually simple and rapid and is nearly always feasible.

Drawbacks:[21] The scars are often disfiguring, recurrent fractures are not infrequent, the

fixator often causes discomfort, and the cost is high.

3.5 Screw fixation alone

Although rarely used, screw fixation is a useful technique that is simple and

inexpensive. Limited invasiveness is another advantage. However, screw fixation is only

suitable for spiral fractures, and additional cast immobilisation is required (Figure 8).

3.6 Monitoring

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Post-operative care is the same as in patients treated by closed reduction in the

operating theatre (section 2.4). If the internal fixation is satisfactory, radiographic

monitoring can be limited to days 30 and 90.

Weight bearing is a challenging issue. In theory, immediate weight bearing is possible

with external fixation, screw-plate fixation, and rigid intra-medullary nailing, except when

stability of the construct is in doubt. We also allow immediate weight bearing in patients

with stable fractures treated by ESIN. In contrast, it seems reasonable to wait until the callus

starts to form (about 1 month) after non-locking screw-plate fixation or after ESIN used to

treat an unstable fracture of both leg bones. In every case, we advocate gradual resumption

of weight bearing, as guided by the pain.

As a rule, we do not add cast immobilisation after internal fixation methods, including

ESIN. However, a resin walking boot may be useful in some cases after ESIN.

Rehabilitation therapy is not indispensable given the low risk of stiffness in paediatric

patients. Self-exercises to maintain muscle strength should therefore be recommended.

Range of motion at the knee and ankle returns to normal with time.

Removal of the fixation material can be performed after 3 months at the earliest,

provided the callus is sufficiently well formed. Ideally, removal should be done after 6 to 12

months.

4 INDICATIONS

Overall, fracture healing is readily achieved in paediatric patients due to the high level

of periosteal activity, and natural remodelling occurs as indicated in section 2.5 above.

Consequently, preference should go to the least aggressive treatment possible, making non-

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operative treatment the best option in most cases. Surgery is thus reserved for patients with

contraindications to non-operative treatment.

The choice between non-operative treatment and surgery as the first-line strategy can

be guided by classifying leg fractures into two main groups: non-displaced or displaced but

reducible and stable; and displaced and unstable, irreducible, and/or comminuted.

4.1 Non-displaced or displaced but reducible and stable fractures

Non-operative treatment is clearly the preferred option in this situation. The contra-

indications are absolute or relative and include the following.

- Although not a contra-indication, a breach in the skin classified Gustilo 1 or 2 should be

trimmed and cleansed, and the cast should be windowed to allow wound monitoring.

- A Gustilo 3 skin lesion or crush injury is, in our opinion, a contra-indication to casting,[4]

which would preclude optimal monitoring of the wound.

- In overweight children, optimal casting is difficult to achieve, and stabilisation by fixation

material is often required.

- Finally, the child and family can be asked about their preferences, and internal fixation may

be offered if they object to 3 months of immobilisation[12,13,15,22,23] (e.g., because the child

has sporting activities or the injury occurs near or during the summer vacation period). The

advantages and drawbacks of both methods should be explained in detail. The option of

internal fixation for reasons of personal preference should be discussed openly, to avoid an

excessively aggressive treatment strategy.

4.2 Displaced and unstable, irreducible, and/or comminuted fractures

Internal fixation seems legitimate in this situation. When feasible, ESIN appears to be

the best option.[11-16,21,23] There are no limitations related to body weight or age.[14,24] Open

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skin lesions do not contra-indicate ESIN.[23,25] Circumspection is in order in overweight

children with unstable fractures near the proximal or distal joint. Screw-plate fixation is a

useful option for proximal and distal fractures and when a secondary fracture line involves

the metaphysis or joint. When feasible, use of the percutaneous route for screw-plate fixation

deserves consideration.[19] Rigid intra-medullary nailing is a good alternative in adolescents

whose skeletal growth is nearly complete.[18]

In theory, external fixation is nearly always suitable. External fixation is extremely

valuable in certain complex fractures.[20] Nevertheless, the complication rate is higher than

with ESIN and rigid intra-medullary nailing.[21] External fixation deserves to be considered

as an alternative to screw-plate fixation if it obviates the need to approach the fracture site. It

remains the most widely used methods for fractures with Gustilo 3 skin lesions.[26]

4.3 Specific situations

Immobilisation in a resin long-leg cast for 1 month is usually sufficient for hairline

fractures.

Stress fractures respond well to rest alone. Immobilisation in a walking boot for 1

month is another option.

In patients with brittle bones due to constitutional disorders, preserving normal leg

alignment is crucial. Non-operative treatment can be used provided a light-weight

immobilisation system is used and weight bearing is resumed rapidly. This is an excellent

indication of ESIN, with sliding nails. The other option is a telescopic intra-medullary nail.

In patients with pathological fractures, casting to allow a staging workup and a biopsy

if needed is the best course of action. ESIN can be extremely useful to stabilise benign bone

lesions.

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In the event of multiple injuries, internal fixation is recommended to facilitate nursing

care.

Floating knee is a rare injury that requires internal fixation. We believe the most

logical sequence starts with treatment of the femur, by supracondylar trans-osseous traction,

taking care to preserve the growth plate. Then, the tibial fracture is stabilised.

Fracture occurring in congenital pseudarthrosis must be treated surgically. Healing is

usually difficult to achieve in this pathology .

5 COMPLICATIONS AND RESIDUAL ABNORMALITIES

Complications can occur with all the available techniques, The complication rate

seems to be lowest with ESIN[11,14,21,27] and highest with external fixation.[21,27]

5.1 Immediate complications

Skin breach: The location of the tibia immediately under the skin tibia carries a risk of skin

injury. The wound must be debrided and cleansed on an emergency basis. Prophylactic

antibiotic therapy should be started at the emergency room and continued for 48 hours.

Infection: Infection is rare when the fracture is closed. Local subcutaneous infection can

develop at the nail entry sites after ESIN or at the pin entry sites during external fixation.

Local debridement is usually sufficient, with concomitant antibiotic therapy if needed.

Infected external fixator pins may need to be changed. If infection develops at the fracture

site, microbiological samples should be collected, and the site should be debrided and

abundantly irrigated. The fixation material should be removed. In most cases,

immobilisation is then achieved by external fixation or, in some instances, casting. Two

intravenous antibiotics should be given in combination.

17

Vascular complications: In the event of ischaemia, revascularizing the limb is an urgent

priority. The fracture should therefore be reduced and stabilised without seeking a perfect

result. Proximal metaphyseal fractures are those most often associated with vascular injuries.

Compartment syndrome: Compartment syndrome must be sought routinely, as the

diagnosis may be difficult in paediatric patients and the symptoms may occur early, within

the first 72 hours. The risk is higher in adolescents. Other risk factors are high-energy

trauma, crush injury, difficult reduction, and casting.[28] Sensory abnormalities in the area

served by the sensory nerves of the involved compartment are usually the first symptoms.

These nerves are the deep peroneal nerve for the anterior compartment, superficial peroneal

nerve for the lateral compartment, lateral saphenous nerve for the superficial posterior

compartment, and posterior tibial nerve for the deep posterior compartment. Pain is the main

symptom however. The pain is typically refractory to analgesic therapy and exacerbated by

putting pressure on the affected compartment. The pressure within the compartment can be

measured and should normally be below 30 mm Hg. Nevertheless, emergency fasciotomy

should be performed at the slightest doubt. In theory, the fasciotomy should involve all four

compartments. However, as the antero-lateral compartment is involved in 90% of cases, the

appropriateness of opening the other compartments may be in doubt. We use elastic loops

slipped under staples to hold the skin open. This method usually allows gradual wound

closure without requiring a skin graft. The absence of arterial pulses is a very late sign and, if

present, indicates a major diagnostic delay.

5.2 Secondary complications

Secondary displacement is chiefly seen after non-operative treatment. If the displacement

is unacceptable, either further reduction under general anaesthesia or cast wedging is

required. Secondary displacement can occur after ESIN and is then usually ascribable to a

18

technical error. Correction may be achievable by adding a cast. Otherwise, the internal

fixation construct must be modified.

Delayed healing occurs mainly in compound fractures or fractures due to high-energy

trauma. Patience is often the best approach in paediatric patients, in whom problems are rare

if the fixation material is sufficiently stable to allow weight bearing. An external fixator can

be replaced by another method if it is poorly tolerated.

Skin impingement by internal fixation material: Skin impingement is not uncommon at

ESIN entry sites. Great care is needed when cutting the ends of the nails. If the fracture is

well healed, the nails can be removed. Otherwise the ends must be cut.

5.3 Late complications

Non-union: Non-union is rare in paediatric patients and occurs mainly in complex cases

(e.g., compound, multifocal, or comminuted fractures). Healing can usually be achieved by

using an external fixator to apply compression forces to the fracture site or by reaming the

intra-medullary canal then implanting a rigid intra-medullary nail (if permitted by the

patient’s age). A fibular osteotomy is indispensable; removing 1 cm of the fibula is

recommended. Excision of the non-union site followed by bone grafting and internal fixation

is less often needed. Infection of the non-union site must be sought routinely to determine

whether appropriate antibiotic therapy is required also.

Mal-union: The potential for natural remodelling has been mentioned in the section on

indications. Most cases of mal-union causing a major deformity eventually require either a

corrective osteotomy or asymmetrical epiphysiodesis if permitted by the patient’s age and

nature of the deformity.

Limb length discrepancy: The difference in limb length is usually less than 2 cm. The

discrepancy may be due to excessive growth of the fractured limb or to impaction of the

19

bone fragments (chiefly in the event of spiral or comminuted fractures). In rare cases,

epiphysiodesis or limb lengthening is required eventually.

Tibio-fibular synostosis: Tibio-fibular synostosis may gradually induce valgus

malalignment. Excision of the synostosis may deserve consideration in this situation.

Refracture: Refracture may occur after removal of the fixation material. External fixation

and screw-plate fixation result in stress shielding and therefore carry the highest risk of

refracture. Consequently, the material should not be removed until a strong callus has

developed. The family must be informed that weight bearing should be resumed only

gradually, if possible with no running or jumping during the first 6 weeks. A 1-month

transition period with a walking boot may be helpful. Impact is best avoided until patency of

the intra-medullary canal is re-established. In theory, the use of intra-medullary fixation

material eliminates the risk of refracture.

CONCLUSION

Leg fractures are common in the paediatric population. Most leg fractures are stable

and readily reduced, a situation in which non-operative treatment is usually effective. Non-

operative treatment is a painstaking technique that requires considerable experience on the

part of the surgeon and close monitoring of the patient. A drawback of non-operative

treatment is the need for a lengthy period of immobilisation, often exceeding 3 months.

Alternative treatments (chiefly ESIN) should be offered to the patient and family, as some

paediatric patients prefer internal fixation to prolonged immobilisation.

Unstable or complicated fractures require stabilisation by external or internal fixation.

ESIN seems to offer the best risk/benefit ratio. When ESIN is not suitable, the other methods

constitute valuable options.

20

Close monitoring during the first few days is crucial regardless of the method used to

ensure the detection of complications, which are rare but potentially devastating.

Disclosure of internet: None of the authors has any conflicts of interest to declare.

21

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FIGURE LEGENDS

Figure 1: Faulty cast wedging procedure

Figure 2: The outer cross-section of the tibia is triangular but the cross-section of the canal

is round.

Figure 3: Elastic stable intra-medullary nailing of the tibia, antero-posterior view

Figure 4: Elastic stable intra-medullary nailing of the tibia, lateral view

Figure 5: The fibula is intact. Persistent varus malalignment due to the inappropriate

direction of the medial nail

Figure 6: The fibula is intact. Both nails are optimally positioned, ensuring optimal

reduction

Figure 7: Bi-focal fracture. The comminution at the distal fracture site required screw-plate

fixation

Figure 8: Fixation of a spiral fracture using screws only

Figure (scenario) A: (1) Partial reduction of the fracture; (2) The first nail is introduced and

advanced across the fracture site; (3) The nail is advanced further but stopped before

reaching the metaphysis; (4) The second nail is advanced alongside the first one; (5) The

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fracture is reduced by external manipulation; (6) The two nails are advanced further and

impacted into the metaphyseal cancellous bone; (7) Progression of the nails is stopped near

the growth plate.

Figure(scenario) B: To correct the persistent valgus, the lateral nail is rotated by 180° to

induce varus.

Figure (scenario) C: To correct the persistent flexion deformity, the two nails are redirected

anteriorly to counteract the forces inducing flexion