Pediatric Tibial Shaft Fractures: Weight Bearing As Tolerated Elizabeth S. Ackerman, MD Mark D. Jenkins, MD Eric T. Jones, MD, PhD John C. France, MD Study conducted at: West Virginia University Hospital Morgantown, West Virginia Université de Montréal Jour de Recherche 2005 May 2005

Introduction Pediatric tibial shaft fractures Third most common long bone injury The current standard of care Closed reduction Long leg casting Period of non-weight-bearing 2-3 weeks No evidence-based guidelines on the length of time that weight-bearing should be restricted

Hypothesis Children who begin weight-bearing within the first two weeks after a tibial shaft fracture have the same rate of complications as those who begin weight-bearing after two weeks

Methods Retrospective chart review Inclusion Criteria Unilateral, closed, stable tibial shaft fracture Aged 1-18 years at the time of fracture Initial treatment with a long leg cast Began weight-bearing on or before the first 28 days after casting Exclusion Criteria Open fracture Pathologic fracture Neuromuscular disorder Fractures requiring internal or external fixation

Methods Data collected: Age Sex Closed/open fracture Mechanism Associated injuries Cast changes and dates Time weight-bearing was cleared Time weight-bearing began Radiographic data Complications Presence of fibular fracture

Methods Complications 32 radiographs were analyzed Alignment that was > 10 degrees of mal-alignment in any plane 32 radiographs were analyzed Purpose of varifying lack of bias in the interpretation of the final radiographs in terms of analyzing the alignment

Methods Treatment All patients were treated by the same physician Long leg casts were applied in 20 to 30 degrees of flexion Changed to a short leg walking cast after 3 weeks A fracture was classified as healed Non-tender fracture site No pain with weight-bearing

Results 148 tibial shaft fractures identified 98 met the inclusion criteria 70 males and 28 females Average follow-up was 2.9 months Range of 0.5-44 months

Results The patients were divided into two groups: Early weight-bearing group 0 - 13 days Later weight-bearing group 14 - 28 days

Results Comparison of the two groups Significant Difference Age Initial fracture displacment (y/n) Fibular fracture (y/n) No Difference Gender Mechanism Fracture location Fracture angulation Time in LLC +/- reduction

Results Weight-bearing permitted Average 6 days No significant difference (p>0.05) Patients began weight-bearing on average at day 14.6 Early weight-bearing group: 6.2 days Late weight-bearing group: 20.6 days Significant difference (p<0.05)

Results Three patients had complications: Early Group Re-fractured 8.5 months after initial fracture Late Group Fracture blisters Malunion Adolescent healed with 10° recurvatum No significant difference in the rate of complications between the two groups (p>0.05)

(mean days ± SD, range) (n=98) Results Patient Data Time to Healing (mean days ± SD, range) (n=98) Age:* 1 – 2 yrs > 2 – 5 yrs > 5 – 10 yrs > 10 – 13 yrs > 13 – 18 yrs Gender: Male Female Initial displacement (n=94):* Yes No Associated injury:* Fibular fracture:* Closed reduction (n=96):* *p < 0.05 27.2 ± 21.2 (14-100) 29.2 ± 11.1 (14-69) 40.1 ± 11.5 (22-73) 60.4 ± 18.1 (44-90) 60.3 ± 18.5 (44-93) 37.8 ± 18.6 (14-93) 32.4 ± 16.6 (16-100) 44.4 ± 18.0 (16-93) 29.1 ± 14.3 (14-100) 45.9 ± 18.5 (26-90) 35.3 ± 17.9 (14-100) 47.2 ± 23.5 (14-100) 32.3 ± 14.0 (14-85) 50.4 ± 22.8 (19-100) 31.1 ± 13.4 (14-85)

(mean days ± SD, range) (n=98) Results Patient Data Time to Healing (mean days ± SD, range) (n=98) Age:* 1 – 2 yrs > 2 – 5 yrs > 5 – 10 yrs > 10 – 13 yrs > 13 – 18 yrs Gender: Male Female Initial displacement (n=94):* Yes No Associated injury:* Fibular fracture:* Closed reduction (n=96):* *p < 0.05 27.2 ± 21.2 (14-100) 29.2 ± 11.1 (14-69) 40.1 ± 11.5 (22-73) 60.4 ± 18.1 (44-90) 60.3 ± 18.5 (44-93) 37.8 ± 18.6 (14-93) 32.4 ± 16.6 (16-100) 44.4 ± 18.0 (16-93) 29.1 ± 14.3 (14-100) 45.9 ± 18.5 (26-90) 35.3 ± 17.9 (14-100) 47.2 ± 23.5 (14-100) 32.3 ± 14.0 (14-85) 50.4 ± 22.8 (19-100) 31.1 ± 13.4 (14-85)

Healing Time Time to healing (days) *p < 0.05 27.9 ± 11.1 (14-62) Early Weightbearing (0-13 Days) (n=41) Later (14-28 Days) (n=55) Time to healing (days) (mean ± SD,range)* *p < 0.05 27.9 ± 11.1 (14-62) 42.3 ± 19.9 (15-100) A multivariate analysis -Early weight-bearing group healed 3.6 days faster

Discussion Early weight-bearing may actually be a common practice No evidence based studies in the literature Recommended NWB 2-3 weeks Our groups were divided Actual weight bearing before 2 weeks Actual weight bearing occurred after 2 weeks

Discussion Three patients had complications: Early Group Late Group 15-year-old male Re-fractured 8.5 months later in a sporting event He was weight-bearing on the first post-cast day Late Group 6-year-old male Developed fracture blisters 11-year-old male Healed with 10° recurvatum

Discussion The time to healing was decreased Early weight bearing Younger age Lack of fibula fracture Nondisplaced fracture

Discussion Strengths Weakness Single institution Consistent treatment Long term Large sample size Weakness Retrospective nature Average length of follow-up 2.9 months (range 0.5-44 months)

Conclusion Hypothesis: Conclusion: Allowing weight-bearing within the first two weeks after a tibial shaft fracture does not increase the rate of complications Conclusion: Proved our hypothesis Early weight-bearing caused no significant increase in complications

Conclusion The low number of complications provides support for a treatment program allowing pediatric patients with tibial shaft fractures to WBAT from the time of injury

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