Comparison of Three Surgical Options for Treatment of Diaphyseal Tibia Fractures in Pediatric Patients

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Background Most pediatric diaphyseal tibia fractures can be treated with reduction and casting. While surgical reduction and fixation is sometimes necessary, there is no clear consensus about optimal implant. Plate osteosynthesis (PO), elastic intramedullary nailing (EIN), and multiplanar external fixation (MEF) are common surgical fixation methods in the skeletally immature patient after failing closed reduction. This study aims to compare the indications and outcomes of PO, EIN, and MEF techniques for surgical treatment of the pediatric diaphyseal tibia fracture. Methods Skeletally immature patients ages 4 to 16 years treated surgically by PO, EIN, or MEF for a diaphyseal tibia fracture at a single, tertiary pediatric hospital were included. Demographic, clinical, radiographic data, and complications were collected retrospectively. Complications were classified according to the Clavien-Dindo-Sink classification. Results In total, 82 patients were included with a median age of 13.4 years (range, 5.69-15.94) and median follow-up of 46 weeks (range, 14-237), of whom 84% (69/82) were male. Most patients received EIN (61%; 50/82), while 23% (19/82) had MEF, and 16% (13/82) had PO. There were no differences across treatment groups for open (p=0.96) and comminuted (p=0.19) fractures. Location of fracture was significantly different by treatment method with middle 1/3 fractures treated mostly by EIN (77%; 34/44) and distal 1/3 fractures treated across all three fixation methods (p=0.002). Patients treated with MEF (47%; 9/19) and PO (46%; 6/13) had higher complication rates compared with those treated with EIN (22%; 11/50). Patients treated with PO and MEF had 6.0 and 6.2 times the odds of having a severe complication, compared to patients who had EIN, controlling for age, weight, and fracture severity (p=0.01, p=0.02). There was no significant difference in other fracture characteristics and outcomes. Conclusion All three fixation types (PO, EIN, and MEF) show similar indications, although fracture location in the diaphysis may influence implant choice. EIN has a lower complication rate compared with PO and MEF and presents a strong option for operative treatment of the pediatric tibia shaft fracture. Levels of Evidence Level III: Case-control study or retrospective cohort study

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