Outcomes and complications following flexible intramedullary nailing for the treatment of tibial fractures in children: a meta-analysis

Epidemiology of Acute Compartment Syndrome After Pediatric Tibial Tubercle and Tibial Shaft Fractures

BACKGROUND

While acute compartment syndrome (ACS) is a well-reported complication after pediatric tibial shaft fractures, prior literature has suggested that pediatric patients with tibial tubercle fractures may be at increased risk of ACS due to the proximity of the tibial tubercle to the anterior tibial recurrent artery. However, this theory was largely based on a series of early case reports without substantiation in larger-scale studies.

HYPOTHESIS/PURPOSE

The purpose of this study is to conduct a population-level analysis of the incidence and risk factors of acute compartment syndrome following pediatric tibial tubercle and tibial shaft fractures. We hypothesize that the rate of ACS would be lower in patients with tibial tubercle fractures when compared with those with tibial shaft fractures.

METHODS

A retrospective cohort analysis of the PearlDiver Mariner database was performed by querying all patients diagnosed with tibial tubercle and tibial shaft fractures between January 2010 and October 2022. Matched cohorts (n=25,483) of patients with pediatric tibial tubercle and tibial shaft fractures were captured using International Classification of Diseases, Ninth Revision (ICD-9), Tenth Revision (ICD-10) billing codes, and age as inclusion/exclusion criteria. Rates of subsequent compartment syndrome were calculated by querying for insurance claims with associated CPT codes for fasciotomy and/or ICD-9/ICD-10 billing codes for compartment syndrome. Student t test and χ2 analyses were used to compare demographics between the tibial tubercle and tibial shaft cohorts.

RESULTS

The rate of ACS was significantly lower in the tibial tubercle cohort (0.46%) than in the tibial shaft cohort (0.70%, P<0.001). Male sex and increased age were associated with an increased risk of developing ACS in both cohorts (P<0.001). In addition, polytrauma was found to be a risk factor for ACS among patients with tibial shaft fractures (P<0.001).

CONCLUSION

We report a low rate of ACS following both pediatric tibial tubercle fractures and pediatric tibial shaft fractures. Among patients with tibial tubercle fractures, male sex, and increased age were noted to be risk factors for ACS, whereas male sex, older age, and polytrauma were risk factors for ACS among patients with tibial shaft fractures.

Displaced Tibia Fractures in Adolescents: Closed Reduction and Casting Versus Flexible Intramedullary Nails

INTRODUCTION

Although there has been a recent trend towards the operative intervention of pediatric diaphyseal tibial fractures, there is sparse literature that supports this trend. This study compares the outcomes in children between 10 and 18 years of age with diaphyseal tibial fractures who undergo nonoperative treatment with closed reduction and casting (CRC) to those who undergo operative treatment with flexible intramedullary nailing.

METHODS

A retrospective chart review was performed of all patients between 10 and 18 years of age who underwent treatment for tibia fractures at the authors home institution between 2005 and 2018. Radiographs and medical records were reviewed for the duration of immobilization, time to fracture healing and complications including delayed union, malunion, nonunion, and surgical site infection. All statistical analysis was performed using an αof 0.05.

RESULTS

One hundred forty one patients (81.8% males) were included in the final analysis. Patients treated with flexible nailing took an average of 7 weeks ( P <0.001) longer than patients treated with CRC to achieve radiographic healing. The average time to full weight-bearing activities was longer by 1 week in the patients treated nonoperatively with CRC ( P =0.001). There was no statistically significant difference in the malunion rates between the 2 groups ( P =0.067), but delayed union and nonunion were exclusively seen in the flexible nailing group. There was a total of 40 complications among 33 (23.4%) patients, most of whom were in the CRC cohort (60.6%, n=20), but there was no statistically significant difference in complication rates between the 2 cohorts.

DISCUSSION

Most adolescents presenting with closed diaphyseal tibial fractures of moderate severity can be successfully treated both nonoperatively with CRC and operatively with flexible intramedullary nailing. However, we recommend an initial attempt at nonoperative treatment be performed in these patients due to the association of more severe complications with flexible nailing.

LEVEL OF EVIDENCE

Level III.