Not Just Small Adults: Operative Versus Nonoperative Treatment in Adolescent Tibial Shaft Fractures

Abstract

Background: The standard of care for tibial shaft fractures in young children is nonoperative management, while in adults, operative treatment is considered the mainstay. There are no clear guidelines on preferred treatment for adolescents. Purpose: This paper aims to 1) identify clinical and radiographic characteristics predictive of malalignment and 2) determine if treatment type affects malalignment risk. Methods: This retrospective cohort study identified patients aged 12 to 16 years old with a tibial shaft fracture at a Level 1 pediatric trauma center. The primary outcome of interest was malalignment, classified as meeting one or more of the following: >5° coronal angulation, >5° sagittal angulation, translation (cortical width or 100% displaced), and/or rotational deformity. Comparative analyses were done to identify risk factors for malalignment. Results: A total of 162 patients were included—initial treatment was “planned nonoperative” for 102 patients and “planned operative” for 60 patients. The malalignment rate was 34% in the planned nonoperative group versus 32% in the planned operative group. In a multivariate regression, older patients [odds ratio (OR)=−0.07, 95% CI: −0.13 to −0.01; P=0.024] and those with 100% initial displacement (OR=−0.35, 95% CI: −0.64 to −0.05; P=0.021) had decreased odds of malalignment, and having increased sagittal angulation (OR=0.02, 95% CI: 0.01-0.04; P=0.002) and a fibula fracture (OR=0.22, 95% CI: 0.03-0.41; P=0.023) increased the odds of malalignment. There was no difference in the rate of malalignment by initial treatment (P=0.289). Having a planned nonoperative treatment (OR=22.7, 95% CI: 14.0-31.5; P<0.001) and having a fibula fracture (OR=8.52, 95% CI: 0.59-16.45; P=0.035) increased the time immobilized. Conclusions: This study provides insight into factors affecting tibial shaft fracture alignment among patients aged 12 to 16 years. This study suggests that the risk of malalignment is higher among patients with increased initial sagittal angulation and concomitant fibula fractures, but the risk of malalignment is comparable in patients initially treated nonoperatively and operatively. Although healing parameters on average were similar, nonoperative treatment results in longer immobilization time and time for unrestricted weight bearing. Level of Evidence: Level III—retrospective comparative study.