1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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 months

9. Results The patients were divided into two groups:
Early weight-bearing group
days
Later weight-bearing group
days

10. 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

11. 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: days
Significant difference (p<0.05)

12. 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)

13. (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)

14. (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)

15. 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

16. 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

17. 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

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

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

20. 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

21. 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

22. Merci beaucoup pour votre attention
Questions?