My 8 yr old just fractured his tibia and fibula playing soccer. The fracture is maybe an inch or two below the knee. The ER gave him a temporary cast tonight, and he will see an orthopedic doc tomorrow to presumably get another, more permanent cast. My concern right now is that his leg is visibly displaced. His leg below the knee splays outward, away from his other, healthy leg. When his legs are pointed straight down (as if he were laying down flat on his back), I would say his foot location is off by about 1-2" from where it should be due to the displacement. Should the doctor move the leg back into the proper position before putting on the cast tomorrow? Would this likely require any screws, etc.? Thank you in advance for any advice!
Sorry about the delay in answering your question, but the website was having technical problems over the weekend.
You probably have gotten this all taken care of by now. But, just for general information: When your son is seen by the orthopedic surgeon, he/she will try to correct the angulation of the tibia.
Children rarely need surgical intervention. Since they have open growth plates (physis), they have a great potential to remodel any angulation that exists in fractures. Adults do not have this potential, and as a result, their fractures need to be reduced anatomically.
Kids also have very thick periosteums. The periosteum is a sheath of soft tissue on the outside of the bone. It carries the blood vessels and nerves to the bone. Again, in children, the periosteum is a very thick rind. As such, it can help to hold the bone in place and provides a lot of blood supply to the healing fracture.
In the olden days (about 15 years ago or so), small reductions such as needed in your sons case, would have been done under local anesthesia, called a hematoma block. The surgeon would inject the area of the break, and then would just move the bone back into place. Now days, if a reduction has to be done, most of the time the patient will be offered conscious sedation.
Then, a long leg cast would be applied, with a good mold to help hold the bone in the correct position. Usually, in a child of this age, a total of about 6-8 weeks is all that is usually needed. Sometimes, the long leg cast would be switched to a PTB or short leg cast once there was callus formation seen on the x-ray. But, it is also acceptable to treat the fracture totally with a long leg cast. (Use of only a short leg cast is reserved for basically nondisplaced fractures - also called hairline fractures. Here, the cast is just acting as a splint, mainly for protection and comfort.)
So, yes, the orthopedic surgeon will usually do a reduction to get the bone as straight as possible. But, in children, some angulation can be accepted, as they have the potential to remodel fractures.
But, you should be aware of a potential problem with children’s fractures just below the knee, at the proximal tibia. If it is a fracture through the growth plate (classified as Salter-Harris fractures), then there is always a potential problem with growth disturbances. This does not happen very often (thankfully), but every patient should be aware of the possibility.
Also, in fractures of the proximal tibia, below the growth plate, in what is called the metaphysis of the bone (the flare portion of the tibia) there is the possibility that the bone will develop an angulation after the fracture has healed. This is called tibia valga, where a valgus deformity occurs. However, even though this deformity occurs (which is thought to be due to the difference in blood supply to the two sides of the bone), the bone will straighten itself up with time. This problem needs to be watched for in all children who have proximal tibia fractures.