Complications and technical failures

Complications associated with distal tibial fractures include:

Delayed wound healing
Infection
Loss of reduction
Malunion
Growth disturbance
Cast complications

Significant swelling, particularly when associated with blistering, may necessitate a delay in surgical treatment.

The limb is stabilized with a splint or split paster until the condition of the skin and soft-tissue envelope has improved.

In some cases, a temporary external fixator is necessary to provide sufficient stability.

Definitive surgery should be delayed until the skin and soft tissues recover.

The distal tibial physis contributes significantly less to longitudinal growth than the distal femur and proximal tibia. Physeal injuries in younger patients, however, may cause significant shortening and angular deformity.

Functional consequences related to premature physeal closure are unusual following transitional injuries, including Tillaux and triplane fractures. This, however, can occur particularly in younger adolescents with clinically important growth remaining. It is, therefore, necessary to keep these patients under surveillance until radiological evidence of growth plate closure.

Clinical and radiographical surveillance is essential after distal tibial physeal injuries.

If growth disturbance is suspected, MRI/CT scan is recommended.

Depending on the age of the patient, premature growth arrest can be treated with:

Bar excision
Osteotomy
Leg lengthening/equalization procedures

Surveillance should continue until there is radiological evidence of normal growth.

Recommended reading:

Nguyen JC, Markhardt BK, Merrow AC, et al. Imaging of Pediatric Growth Plate Disturbances. Radiographics. 2017 Oct;37(6):1791–1812.

Loss of reduction may result from inadequate fixation of an unstable injury.

This can be prevented by:

Assessing stability after reduction
Confirming stability after fixation
Applying a molded cast
Using suitable implants, eg, K-wires of appropriate size
Application of K-wires in a stable configuration

Infection in children is less common than in adults.

This may complicate surgical fixation or occur as a consequence of an open fracture.

The risk is increased with:

Unhealthy or broken skin
Limb swelling
Tethered skin around K-wires
Delayed removal of protruding K-wires

Malunion is usually a consequence of inaccurate reduction and ineffective fixation.

Although the pediatric skeleton has the capacity to remodel, reduction should be as accurate as is practically possible.

Malalignment may be accepted, provided there is a high probability of successful remodeling, and this requires an appreciation of the remodeling capacity at the fracture location, the age of the patient, and the plane of angulation.

Managing fractures with a cast is common in pediatric practice.

This requires attention to detail to maximize the likelihood of successful treatment. Complications may occur during application, treatment, and removal.

Preventive measures during application:

Padding pressure points (eg, malleoli, patella, fibular head, common peroneal nerve)
Ensuring a short leg cast is below the fibular neck to avoid common peroneal nerve compression
Avoiding tight application of cast bandage
Delayed completion of a cast if swelling is anticipated
Ensuring complete exposure of all toes to allow assessment of circulation

Preventive measures after cast application:

Elevation of the leg
Ensuring the cast and padding is kept dry
Providing clear instructions to carers about monitoring toe perfusion and swelling
Avoiding insertion of objects between cast and skin

Preventive measures during cast removal: