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4 year old with tibia fracture. 3 weeks later leg healing wrong

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My 4 year old had a spiral fracture from getting hit by a swing at the playground. He was put in a plaster cast from high thigh to toes. After a week we went back for a xray and consult and the leg was healing nice and it was aligned. We just went back today for a 3 week check and the tibia is completely unaligned.

The doc told me he was going to consult some other docs and contact me tomorrow.

He did say that conservative treatment is often better in children and that they can straighten themselves out with time. That just sounds wrong to me. Will this leg really magically straighten out? Will it hurt him to walk/run/play once the cast is removed? It just sounds painful to walk on a unaligned leg. If surgery and pins will help him in the long run wouldn't that be better?

Thanks for input.
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replied March 10th, 2011
Especially eHealthy
LittleHyperTibia,
Kids are great and Mother Nature is the best orthopedic surgeon. It is not magic that children's fractures will straighten in time, it's just how the long bones remodel and grow. Some factors that affect how a bone will remodel are: age of the child, where along the shaft the fracture is located, and the degree of deformity.
It is amazing, how large of an angulation that can be corrected by growth. Another deformity that can be corrected is offset. Some fractures are intentionally left in bayonet apposition, with a few centimeters of overlap. It is known that in femur fractures, the injury will cause overgrowth. Thus, if the bones are put back end to end, the injured leg will end up longer than the uninjured one. Again, Mother Nature was taking care of broken bones long before there were orthopedic surgeons.
As to walking on a leg that has a tibia fracture, discomfort is the guide. As the fracture heals, the discomfort subsides. And if it doesn't hurt, it's almost impossible to keep a child off of it. That's okay. Because the bone actually heals better if stress is applied to it (Wolff's Law). After the cast comes off, there will almost always be a large mass of callus around the fracture site (how the body glues the ends back together). There may be some residual deformity, but it's rarely a problem. As long as the ends of the bone don't move, there won't be pain. The child will have to work out the atrophy and stiffness, of course. Children usually don't do too well in formal physical therapy. They won't do anything that hurts, they know what to avoid and when to stop. Most kids just play themselves back into shape.
Now, there is one caveat. One deformity that WILL NOT CORRECT itself is ROTATION. That deformity must be looked for carefully and reduced, for growth will not remodel it.
Surgery in children can actually be more dangerous than in adults. They don't do too well with general anesthesia and, occasionally, unknown medical conditions are brought out by the stress of surgery (with unfortunate results). Luckily, surgery is rarely warranted in children with closed long bone shaft fractures.
You should discuss all of your concerns with your son's orthopedic surgeon. Every child is different. Every fracture has its own personality. Children are not little adults. The two persons in the best position to determine the best course of action, are the surgeon who has examined your son and has access to all of his studies, and, of course, you.
Good luck.
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replied March 11th, 2011
Thank you so much for your reply.

I guess I left out some important info (atleast to me). We are currently living in Northern Europe and usually we reside in the States. We don't really know if wait and see approach is the right thing or not.

The fracture is towards the middle of the tibia and it is a spiral fracture. They applied the cast 2 weeks ago, we had an xray before the casting, and it was aligned, they applied the full length plaster cast and didn't take another x-ray. They lifted the leg up and down many many times while trying to apply the cast and he even held the leg up by his own without any assistance. He was howling/crying at this point, because of pain.

The bones are angled at a 20 degree angle, so they are 20 degrees off.

We don't know if we should stay here and wait it out or go back to the states and see a specialist there. Here they want to wait and see if it corrects itself while he grows over time.

This really wasn't part of the plan.
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replied March 11th, 2011
Especially eHealthy
LittleHyperTibia,
Spiral fractures are usually the result of a torsional mechanism and transverse fractures (with or without a butterfly fragment) are usually the result of a three point bending mechanism (like from being hit with a car bumper). So, it's a little confusing that he would have a spiral fracture from a direct blow. Did he twist at impact or jump from the swing, landing with a twist? Oh well, anyways. It sounds like this was a low energy injury, so the initial displacement of the fracture should have been small. Also, children have a very thick periosteum around their bones. This sleeve can be very helpful in keeping the fragments aligned. That's why your son could hold his leg up himself, the periosteum was acting as an internal splint. It is also very important in the healing process, as it supplies a significant portion of the blood supply to the outside of the bone.
There is a specific fracture that is unique to small children, called a "toddler's fracture". It is a spiral fracture of the tibia, after minimal or no witnessed trauma. Often the child just starts limping and x-rays show this fracture. This is usually seen around the age of 18 to 24 months, hence the name.
A 20 degree angulation can be corrected with growth. However, the fracture is at the "sticky" stage and now is the time to attempt a better reduction. (Just be sure not to get into the trap of "I can make this a tiny bit better", followed by "Oops" - also known as "the enemy of good is better".) Often a little judicious pressure in the right spots will reduce the fracture greatly. This is usually done while applying a cast, molds are placed to align the fracture and hold it there. Sometimes, if a cast is well fitting, it can be cut and wedged to apply the correct pressure at the exact spots needed.
The problem you have now, is that you can't wait much longer in making a decision. Now is the time to attempt a better closed reduction. Kids heal so quickly. In an adult, you would have a couple more weeks to do some tinkering. So, you are in a sticky situation, no pun intended.
You should probably contact a pediatric orthopedist here in the States and e-mail him/her your son's x-rays, this weekend. He/she would then be able to inform you as to the need of further treatment or if it can be left up to Mother Nature. That would be much cheaper than flying back to the States, just to be told that everything is fine.
Please do not post the x-rays to this forum, as that would be inappropriate. You should contact a "pedi pod" that would be able to enter into a patient-doctor relationship with your family as needed.
It's difficult, getting healthcare in a foreign country. Most western European countries have excellent medical care. It's just a little different from what we are used to. For your own peace of mind, contacting a specialist is probably the best way to go. Hope you have a good weekend, it may be busy. Good luck.
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replied September 10th, 2013
pain on knee after cast removal - spiral tibial fracture
My son is 4 years old and he has a spiral tibial fracture on his right leg. Doctor removed the cast after 7 weeks. The X-ray report shows he is improving . Already 10 days left of the cast removal but now-a-days he is feeling pain on his knee and that fracture place too. Sometimes swelling also appears on knee After application of some diclofenac or anti-inflammatory gel it goes. Is this normal or some criticality is there ?

Please suggest
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