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Tibial Shaft Fracture

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Other Names

  • Toddler's Fracture
  • Toddler Fracture
  • Childhood Accidental Spiral Tibial (CAST) fracture




  • Account for 4% of acute sports related fractures[1]
  • 25% of all tibial shaft fractures occur during sport and recreation related activities[2]
  • Incidence
    • Across all populations 16.9 cases per 100,000/year[3]
    • Males have 21.5 cases per 100,000/year (age 10 - 20) women have 12.3 cases per 100,000/year (age 30 - 40)
  • Pediatrics[4]
    • 3rd most common pediatric lone bone fracture (behind femur, humerus)
    • 39% occur in the midshaft (50% in the distal third, 11% in the proximal third)
    • Apprixmately 10% are open



  • Low energy
    • Usually torsional, indirect injury
    • For example twisting of leg with foot planted
  • High energy
    • For example MVC, MCC
    • Direct trauma to leg
    • Often more severe soft tissue injuries

Pediatric Considerations

  • Low energy mechanism is most common
    • Most common in toddlers
    • Pivoting on a planted foot
    • Direct trauma with a planted foot
  • High energy mechanism can occur due to MVC, etc
    • More common in adolescence
  • Toddler Fracture
    • AKA Childhood Accidental Spiral Tibial (CAST) fracture
    • Seen in young ambulating toddlers age 9 months to 3 years
    • Defined as a non-displaced spiral fracture of tibial diaphysis

Associated Conditions

Risk Factors

Differential Diagnosis

Clinical Features

  • History
    • Mechanism is important to clarify
    • Patients will report pain, swelling, inability to bear weight
    • Pediatric patients: pain, deformity, difficulty weight bearing
  • Physical Exam: Physical Exam Leg
    • Inspect for soft tissue injuries (contusions, blisters, open wounds)
    • Inspect for deformities, angulation, malrotation
    • Warmth, tenderness over fracture site
    • Critical to perform thorough neurovascular examination
    • Can patient plantar and dorsiflex?
    • Is sensation intact for Common Peroneal Nerve, Tibial Nerve?
    • Palpate all 4 compartments to ensure they are soft
    • Serial examinations are also required to evaluate for progression to acute compartment syndrome
  • Special Tests




  • Indications
    • Intra-articular fracture extension or suspicion of joint involvement
    • CT ankle for spiral distal third tibia fracture (eval for posterior mal fracture)


  • Indications
    • Suspicion for pathologic or stress fracture
    • Rule out an occult fracture


Oestern and Tscherne Classification of Closed Fractuer Soft Tissue Injury

  • Grade 0: Injuries from indirect, negligible soft-tissue damage[6]
  • Grade I: Superficial contusion/abrasion, simple fractures
  • Grade II: Deep abrasions, muscle/skin contusion, direct trauma, impending compartment syndrome
  • Grade III: Excessive skin contusion, crushed skin or destruction of muscle, subcutaneous degloving,
    • High risk of acute compartment syndrome, and rupture of major blood vessel or nerve

Gustilo-Anderson Classification of Open Tibia Fractures

  • Type I: Limited periosteal stripping, clean wound < 1 cm[7]
  • Type II: Mild to moderate periosteal stripping, wound >1 cm in length
  • Type IIIA: Significant soft tissue injury (often evidenced by a segmental fracture or comminution)
    • Significant periosteal stripping, wound usually >5cm in length, no flap required
  • Type IIIB: Significant periosteal stripping and soft tissue injury, flap required due to inadequate soft tissue coverage
  • Type IIIC: Significant soft tissue injury (often evidenced by a segmental fracture or comminution)
    • Vascular injury requiring repair to maintain limb viability

Pediatric Tibial Shaft Fracture Patterns

  • Incomplete: greenstick fracture of the tibia and/or fibula
  • Complete: complete fracture of the tibia with or without ipsilateral fibula fracture or plastic deformation
  • Tibial spiral fracture (Toddler's Fracture): nondisplaced spiral or fracture of the tibia with intact fibula in a child under 2.5 years of age



  • Most athletes will return to sport, however only a limited proportion will return to their pre-injury level[8]
    • Surgery: significantly improved return-to-sport rates, decreased return-to-sport time
  • Pediatric management
    • Traditionally, about 4.5% of pediatric tibial fractures were managed surgically[4]
    • A 2018 study in Finland found about 30% of pediatric tibial shaft fractures were managed surgically[9]


  • Depending on mechanism, important to follow ATLS principles
    • Identify any other acute, limb or life threatening injuries
  • Immobilization
  • Open fractures require antibiotics
    • Typically a first generation cephalosporin
    • Add aminoglycoside, penicillin for grossly contaminated fractures
  • Vascular injuries require consultation with a vascular surgeon


  • Pediatric Indications
    • The vast majority of pediatric cases are non-operative
    • Tibial shaft fractures within acceptable parameters at presentation or after closed reduction (see table)
  • Adult population
    • Must meet acceptable parameters from table below
    • Patients who may be non-ambulatory at baseline, non-surgical canddiates
  • Treatment
    • Long Leg Cast, convert to brace around 4-6 weeks
    • Toddlers fractures 3-4 weeks, older children 6-8
Acceptable Angulation Parameters for Nonoperative Management of Tibial Shaft Fractures
Age Coronal Angulation Sagittal Angulation Shortening Cortical Overlap Rotation
Kid <8 <10° <10° <1 cm >50%
Kid ≥8 <5° <10° minimal >50%
Adult <5° <10° <1 cm >50% <10°


  • Indications
  • Pediatric indications
    • Similar to above except
    • Fractures that do not meet initial acceptable radiographic criteria for closed reduction
  • Technique
    • External fixation
    • Rigid intramedullary nailing
  • Additional Pediatric Technique
    • Flexible intramedullary (IM) nailing
    • Plate osteosynthesis

Rehab and Return to Play


  • The evidence on the optimal modality of rehabilitation for these injuries remains limited[4]

Return to Play

  • Needs to be updated


  • Acute Compartment Syndrome
    • Can occur acutely following injury or during the postoperative period
    • Increased risk: increased body habitus, complexity of fracture pattern
  • Infection
    • Increased risk: open fractures, higher Gustilo-Anderson grade
    • Osteomyelitis is a rare complication
  • Wound healing difficulty
  • Late complications
    • Malunion
    • Nonunion
    • Leg-length discrepancy
    • Angular deformity
    • Knee Pain
  • Unique pediatric complications

See Also


  1. Court-Brown, CM, Wood, AM, Aitken, S. The epidemiology of acute sports-related fractures in adults. Injury. 2008;39:1365-1372.
  2. Connelly, CL, Buckman, V, Jenkins, PJ, Court-Brown, CM, McQueen, MM, Biant, LC. Outcome at 12 to 22 years of 1502 tibial shaft fractures. Bone Joint J. 2014;96B:1370-1377.
  3. Larsen, Peter, et al. "Incidence and epidemiology of tibial shaft fractures." Injury 46.4 (2015): 746-750.
  4. 4.0 4.1 4.2 MooneyJ, HennrikusW. Fractures of the shaft of the tibia and fibula. In: Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkins fractures in children. 8th ed. Philadelphia: Wolters Kluwer Health; 2014. p 1874-932.
  5. Kelsey JL, Keegan TH, Prill MM, Quesenberry CP Jr, Sidney S. Risk factors for fracture of the shafts of the tibia and fibula in older individuals. Osteoporos Int. 2006 Jan;17(1):143-9. doi: 10.1007/s00198-005-1947-8. Epub 2005 Aug 9. PMID: 16088362.
  6. Valderrama-Molina, Carlos Oliver, et al. "Intra-and interobserver agreement on the Oestern and Tscherne classification of soft tissue injury in periarticular lower-limb closed fractures." Colombia Médica 45.4 (2014): 173-178.
  7. Kim, Paul H., and Seth S. Leopold. "Gustilo-Anderson classification." (2012): 3270-3274.
  8. Robertson GAJ, Wood AM. Return to Sport After Tibial Shaft Fractures: A Systematic Review. Sports Health. 2016;8(4):324-330.
  9. Stenroos A, Laaksonen T, Nietosvaara N, Jalkanen J, Nietosvaara Y. One in three of pediatric tibia shaft fractures is currently treated operatively: a 6-year epidemiological study in two university hospitals in Finland treatment of pediatric tibia shaft fractures. Scand J Surg. 2018 Jan 1:145749691774822.
  10. Jeganathan K, Elangainesan P, Kam AJ. Management of Toddler's Fractures: A Systematic Review. Pediatr Emerg Care. 2020 Jan 20. doi: 10.1097/PEC.0000000000002005. Epub ahead of print. PMID: 31977777.
Created by:
John Kiel on 7 July 2019 07:17:54
Last edited:
5 June 2021 20:59:38
Lower Extremity | Trauma | Pediatrics | Leg | Fractures | Acute