SUPPLEMENT
Tibia Shaft Fractures in Adolescents: How and When Can
They be Managed Successfully With Cast Treatment?
Christine A. Ho, MD*w
Abstract: Despite the increasing popularity of operative treat-
ment in adolescent tibia fractures, casting remains a viable first-
line treatment. Because the selection bias in published reports
does not allow direct comparison between casting and flexible
nail treatment of closed pediatric tibia fractures, it is unclear
whether flexible nailing offers any advantages over casting. This
overview discusses parameters of acceptable alignment, in-
dications, techniques for successful reduction and casting, sub-
sequent inpatient and outpatient management including
wedging of casted tibia fractures, expected outcomes, and
comparison of casting with flexible nailing. As with any ortho-
paedic procedure, careful attention to patient selection, in-
dications, and detail facilitates successful cast treatment in this
older pediatric population.
Key Words: tibia fracture, casting, adolescents, pediatric
(J Pediatr Orthop 2016;36:S15–S18)
A lthough the vast majority of tibial shaft fractures in
children heal quickly with simple cast immobilization,
flexible nail fixation has become more popular, especially
in the adolescent population.1–5 However, there have
been significant complications reported with the use of
flexible nails in pediatric tibia fractures, including com-
partment syndrome,6,7 malunion, nonunion, and nail
migration.7,8
At the author’s institution, casting continues to be
the mainstay of treatment of all closed tibial shaft frac-
tures, including in the adolescent population. In our re-
port of 75 adolescent tibial shaft fractures treated with
reduction and casting, only 3 patients failed cast treat-
ment and subsequently underwent surgical fixation, al-
though 61% of patients required longer than 3 months of
immobilization (which included removable boots).9 In
addition, the only reported complication in this cohort
From the *Texas Scottish Rite Hospital for Children—Children’s
Health Dallas; and wDepartment of Orthopaedics, University of
Texas Southwestern Medical School, Dallas, TX.
The author declares no conflicts of interest.
Reprints: Christine A. Ho, MD, Texas Scottish Rite Hospital for Chil-
dren – Children’s Health Dallas, Department of Orthopaedics,
University of Texas Southwestern Medical School, 1935 Medical
District Dr., E2300-E2.01, Dallas, TX 75235. E-mail: Christine.
Ho@childrens.com.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop  Volume 36, Number 4 Supplement 1, June 2016
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
was a single heel ulcer that healed uneventfully. There
were no compartment syndromes.
Although individual adolescents can vary greatly in
their skeletal maturity, many surgeons define an adoles-
cent as girls aged 10 years or above and boys aged 12
years or above.9 At this age, there is <4 years of skeletal
growth remaining, and remodeling is limited compared
with younger patients, making anatomic alignment more
of a consideration.
PRINCIPLES OF MANAGEMENT
Before discussion of management, the parameters of
acceptable alignment for tibial fractures must be defined.
The seminal works of Sarmiento10 clearly define acceptable
limits for cast/functional brace treatment of adult tibial
shaft fractures as 5 degrees of coronal angulation, 10 to 15
degrees of sagittal angulation, <50% displacement, and 10
to 15 mm of shortening,11 and these parameters continue
to be accepted today.12,13 Interestingly, the acceptable
parameters for alignment for tibial diaphyseal fractures in
pediatric patients below 8 years of age are not much more
than for adults, with 10 degrees of coronal and sagittal
angulation, 50% translation, and 10 mm of shortening as
published guidelines.14,15 It follows that adolescent tibial
shaft fracture guidelines must fall somewhere between the
parameters for children and adults although there are no
published studies relating final radiographic alignment in
this age group with clinical outcomes or arthritis.
When considering cast treatment, thought must be
given to the energy of injury, surrounding soft tissue
swelling, pattern of the fracture, other concomitant in-
juries, the size of the leg and the patient, and whether the
fracture is open or closed. In general, most surgeons will
treat adolescent tibia shaft fractures with surgery in the
following situations:
 open fractures,
 large, obese children that are difficult to cast and are at
increased risk for compartment syndrome,7
 severe swelling with a concern for compartment
syndrome,
 segmental fractures,
 polytrauma,
 floating knees, and
 patterns that cannot be controlled in the cast (espe-
cially >10 degree varus with an intact fibula).16
Patients and parents should be warned that cast treat-
ment may require longer than 3 months of immobilization,
www.pedorthopaedics.com | S15
Ho J Pediatr Orthop
and that the return to full activities occurs at an average
of 15 weeks.9 However, it has not been demonstrated
that time to union and time to return to activities are
sooner for tibia shaft fractures treated with flexible nail-
ing.5,6,17
For patients who do not required formal reduction
of a minimally displaced fracture, a well molded long-leg
cast can be placed with postcasting radiographs to verify
maintenance of alignment. When the fracture requires
manipulation, this is best accomplished with the child
under conscious sedation in the emergency room or op-
erating room, with fluoroscopy to check the alignment
after the initial application of cast material. A qualified,
experienced assistant such as a cast technician is
extremely helpful, especially in unstable patterns and
large legs. Careful padding around areas of prominence
(especially the Achilles insertion and calcaneus) can avoid
skin breakdown. A 3-point mold is crucial in counter-
acting the deforming forces, which is typically varus, es-
pecially in tibia fractures with an intact fibula. Unlike
adults, Achilles contractures are not typically encoun-
tered after casting in the pediatric population, and 15 to
20 degrees of plantar flexion can be helpful. Knee flexion
of 30 to 45 degrees in the cast helps to provide rotational
control and prevent a noncompliant teenager from
weight-bearing. If fiberglass is used for the cast, the au-
thor strongly recommends univalving the cast to allow for
expected swelling and to decrease the risk of compartment
syndrome.
Our institution routinely admits to the hospital tibia
fractures that require reduction and casting for soft tissue
monitoring, elevation, and neurovascular monitoring to
assess for any changes in examination. These patients are
discharged with a large pillow to elevate the leg and re-
main on bedrest for 48 hours after casting to ensure
continued elevation. They are instructed to call the clinic
(or return to the emergency department if after hours or
on the weekend) if the child develops pain or swelling that
does not improve with elevation and oral pain medi-
cations.
After casting, close radiographic monitoring is re-
quired for the first 1 to 2 weeks as there may be some loss
of alignment as the soft tissue swelling resolves. Some
fractures may require 3 consecutive weeks of radiographic
monitoring. Wedging casts in the clinic is an essential
component to successful cast treatment as this can im-
prove angulation in the first few weeks without the need
for further sedation.9,14 The author recommends an
opening wedge technique to avoid the risk of fracture
shortening and skin impingement that can occur with a
closing wedge technique. A cast saw is used to carefully
cut circumferentially around the cast, perpendicular to
the long axis of the tibia, at the level of the apex of the
fracture (Fig. 1). Small commercially available spacers up
to 1 cm in width can be used to open the wedge on the cast
side opposite the location of the fracture apex.
Tibia fractures that are length unstable are non–
weight-bearing until callus is present (generally 4 to 6 wk).
At this time, patients may be transitioned into a short leg
S16 | www.pedorthopaedics.com
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 Volume 36, Number 4 Supplement 1, June 2016
cast or a removable fracture boot, with gradual return to
weight-bearing as per the patient’s comfort.
The treating practitioner must be aware that this
can be a labor intensive process, requiring multiple fol-
low-up radiographs and clinic visits to ensure alignment is
maintained, and that interventions such as wedging or
even completely replacing an ill-fitting cast may be
needed. This must be discussed with the family before
embarking on cast treatment. Any pain in the cast must
be investigated by the treating practitioner. Compartment
syndrome must be strongly considered in the setting of
increasing, unrelenting pain and swelling that occurs in
the first 48 to 72 hours. It has been shown that increasing
agitation, anxiety, and need for analgesic medication are
the most sensitive indicators of compartment syndrome in
the pediatric population.18 After the swelling has sub-
sided, pain in the cast may be because of skin irritation
from the cast rubbing, and this may lead to ulcerations
and pressure sores if not remedied. Objects placed in the
cast by the child, such as pencils, erasers, coins, and even
small toys (the author has encountered a dinosaur inside a
cast) may also be offenders and must be removed.
DISCUSSION
As treatment of pediatric long-bone fractures be-
comes increasingly more surgical, casting is in danger of
becoming a lost art. The advantages of flexible nailing
over casting of adolescent tibia fractures are unclear, es-
pecially since all of the reports regarding flexible nails in
pediatric tibias combine both open and closed injuries,
leading to bias in these reports.
Duration of Immobilization
Sarmiento initially transitioned his adult patients
from a long-leg cast to a functional brace at an average of
3.8 weeks.11 Our institution reported an average duration
of immobilization of 13.8 weeks with the majority of
patients transitioned to a short leg cast or boot at the
6-week mark.9 Many tibia fractures require a cast even
after surgical stabilization. Sankar et al5,6 reported that
all surgically stabilized tibia fractures were immobilized,
with an average of 7 weeks in a cast.
Union Time
In the author’s institution’s casted pediatric pop-
ulation, the mean return to activities was at 15 weeks,
which compares favorably to a mean union time of 18.1
weeks for casted adults.11 Union time with flexible nails
has been reported by Sankar et al5,6 to be between 11 and
13 weeks, but Srivastava et al17 reported a union time of
22.5 weeks for 9 closed tibial fractures treated with flex-
ible nails.
Malunion Rates
Sarmiento reported an 11% rate of angulation >7
degrees in the coronal plane, 5% rate of angulation >10
degrees in the sagittal plane, and 1.4% rate of shortening
>20 mm in adults treated with casting.10 The author’s
reported experience in adolescent casted tibias was 5%
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J Pediatr Orthop  Volume 36, Number 4 Supplement 1, June 2016 Casting Adolescent Tibia Shaft Fractures

FIGURE 1. A, A 13+ 10-year-old boy twisted his leg while sliding into base during baseball, resulting in a diaphyseal distal tibia
fracture with a proximal fibula fracture, with loss of reduction and valgus malalignment 1 week after initial reduction. B,
Alignment improved after wedging of the cast in the clinic. C, Acceptable alignment at final follow-up, 3 months postinjury.

rate of angulation >5 degrees in the coronal plane and
3% rate of angulation >10 degrees in the sagittal plane.9
Goodwin et al1 published that 10% of their pediatric tibia
fractures treated with flexible nails had angular deformity
>10 degrees, and Sankar et al6 similarly reported a 12%
rate of malangulation >10 degrees.
Complications
The only complication in our reported adolescent
series was 1 heel ulcer.9 No patient suffered a compart-
ment syndrome. Three of 75 patients (4%) failed cast
treatment and were treated with surgical stabilization (all
3 of these were involved in vehicular collisions). During
the study time period (7 y), only 6 other patients under-
went immediate surgical stabilization. Pandya et al7 re-
ported a 20% rate of compartment syndrome in their
patients treated with flexible nails, and Sankar et al6 re-
ported a 2% rate of compartment syndrome with another
2% of patients requiring an unplanned return to the op-
erating room. It must be emphasized that the flexible nail
cohorts included open fractures, which suffered higher
energy injuries and therefore may these groups may have
already been biased toward more complications.
It has not been demonstrated that closed pediatric
tibia fractures treated with flexible nails have faster union
rates, decreased complications, or improved functional
outcomes when compared with casting, although se-
lection bias makes it impossible to compare the groups.
The possibility for prolonged casting in adolescents may
be minimized by transitioning to a fracture brace instead
of a short leg cast or boot. There is no data comparing the
quality/value/safety of flexible nailing versus casting of
adolescent tibia fractures.
In short, successful casting is accomplished by the
following:
 establishing a common understanding between the
treating practitioner and family regarding expected
treatment duration, need for clinic and radiographic
follow-up, and need for possible clinic interventions;
 having a low threshold for hospital admission to
monitor for swelling and pain;
 strict elevation of the fractured leg for at least 48 hours
after casting;
 experienced assistants present for cast application(in
the author’s institution, these are certified cast techni-
cians);
 experience in the art of casting with special expertise in
molding and wedging;
 meticulous attention to padding prominent areas in the
cast; and
 immediate investigation of any pain reported in the
cast.

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Ho J Pediatr Orthop
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