The document discusses 5 pediatric orthopedic imaging case studies of children presenting with tibia and fibula fractures, including Salter-Harris fractures. It provides imaging and details on each case, discussing factors like fracture classification and treatment approaches. The document also reviews topics like tibia fracture patterns, risks of compartment syndrome, and outcomes of different treatment methods for Salter-Harris II distal tibia fractures.

1. Pediatric Orthopedic Imaging Case Studies
Kelsey Lena, MD1, Danielle Sutton, MD1, Virginia Casey, MD2
Departments of Emergency Medicine1 & Orthopedic Surgery2
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
Pediatric Orthopedic Imaging Mastery Project
April 2022

2. Disclosures
▪ This ongoing pediatric orthopedic imaging interpretation series is proudly
sponsored by the Emergency Medicine Residency Program at Carolinas
Medical Center
▪ The goal is to promote widespread imaging interpretation mastery.
▪ There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. It’s All About The Anatomy!

4. The Physics of X-Rays
• How far an X-ray projects depends on the density of tissue that is to be
penetrated
• If there is no tissue, the color of the x-ray will be black
• The greater the density, the lighter the color

5. Reading Systematically
• Identify you are reviewing the correct patients imaging
(name, date of birth, date of imaging)
• Review both AP and lateral views, as this can help you
describe the fracture/deformity in both planes
• X-rays of two adjacent joints must be taken or a joint
injury could potentially be missed
• Identify which bone and what fractured part of the bone is
injured
Diaphysis
Metaphysis
Epiphysis

6. CASE #1:
15-year-old pedestrian stuck presents with bilateral open tibia/fibula fractures.

7. CASE #1:
A 15-year-old pedestrian stuck
presents with bilateral open
tibia/fibula fractures.
He undergoes bilateral open
reduction and internal fixation.

8. CMC/LCH Pediatric Tibia
Fracture Cases
www.EMguidewire.com

9. Tibia Fractures
• Account for 15% of all pediatric fractures
• ⅓ most common long bone fracture in children
• Boys >> girls
• Mechanism of injury:
• Toddlers: fall or twisting mechanism
• Adolescents: direct blow

10. Pediatric Tibia/Fibula Shaft Fracture Patterns
Incomplete • Greenstick fractures – partial thickness fracture where the
cortex & periosteum are only disrupted on one side of the
bone
Complete • Complete fractures with or without ipsilateral tibia/fibula
fracture
Spiral Fractures
(Toddler’s Fractures)
• Non-displaced spiral fractures of the tibia with an intact
fibula in a child under 2 ½ years of age
Salter Harris
Fractures
• Fractures involving the physis and with potential injury to
the growth plate.

11. CASE #2:
14-year-old suffers a leg injury playing football.

12. CASE #3:
14-year-old suffers a skateboard crash.

13. .
CASE #4:
8-year-old seen after a fall.

14. CASE #5:
14-year-old presents after a dirt bike crash.
Because this fracture was
non-displaced, it was
successfully managed
with simple casting and
close follow-up.

15. Pediatric Tibia/Fibula Fractures: Clinical Presentation
Physical
Exam
• Symptoms and physical finding range widely based on the severity of
the injury. Always assess the joint above and the joint below the area of
suspected injury.
Neurologic
Assessment
• The peroneal nerve wraps around the fibular head
• Peroneal neuropathy - foot drop, sensory dorsal foot numbness
Vascular
Assessment
• Understand the risks for compartment syndrome (see study)
• Assess for warm, pink skin with capillary refill <2 seconds
• Ensure femoral, DP, PT pulses are present
• The anterior/posterior tibial artery are vulnerable to injury

16. • Most tibial fractures can be managed with closed reduction and casting
(<5-10º of angulation and <1 cm of shortening)
• Generally accepted indications for surgical treatment:
• Open fractures
• Fractures with a “floating knee”
• Several soft tissue swelling and/or concern about compartment syndrome
• Vascular injuries
• Fractures in which adequate alignment could not be achieve
• Fractures in the setting of polytrauma

17. Do Patient-specific or Fracture-specific Factors Predict
the Development of Acute Compartment Syndrome
After Pediatric Tibial Shaft Fractures?
Eric D. Villarreal, MD,* Jesse O. Wrenn, MD, PhD,† Benjamin W. Sheffer, MD,*
Jeffrey R. Sawyer, MD,* David D. Spence
, MD,* and Derek M. Kelly, MD*
Background: Tibial shaft fractures are the most common injuries
preceding acute compartment syndrome (ACS), so it isimportant to
understand the incidence of and risk factors for ACS after pediatric
tibial shaft fractures. Thepurposesof thisstudy wereto determinethe
rate at which ACS occurs and if any patient or fracture character-
istics are signi cantly associated with developing ACS.
M ethods: All patients aged 5 to 17 years treated for a tibial shaft
fracture at a level 1 pediatric trauma center, a level 1 adult
trauma center, and an outpatient orthopaedic practice between
2008 and 2016 were retrospectively identi ed. Demographics,
mechanisms of injury, and fracture characteristics were collected
from the medical records. Radiographs were reviewed by study
authors. ACSwasdiagnosed clinically or by intracompartmental
pressure measurement. Univariable analysiswasperformed using
the Fisher exact test for nominal variables and simple logistic
regression for continuous variables. M ultivariable analysis was
performed using stepwise logistic regression.
Results: Among 515 patientswith 517 tibial shaft fractures, 9 patients
(1.7%) with 10 (1.9%) fractures developed ACS at a mean age of
15.2 years compared with a mean age of 11 years in patients without
ACS (P= 0.001). One patient with bilateral tibial fractures developed
ACS bilaterally. Age greater than 14 years (P= 0.006), higher body
mass index (P< 0.001), motorcycle or motor vehicle accidents (P=
0.034), comminuted and segmental tibial shaft fractures (P< 0.001),
ipsilateral bular fracture (P= 0.002), and associated orthopaedic in-
juries (P= 0.032) were all signi cantly more common in the ACS
group.
Conclusions: ACS developed in 1.7% of the patients with tibial
shaft fractures in this retrospective study—a rate signi cantly
lower than previously reported. Agegreater than 14 years, higher
body mass index, motor vehicle or motorcycle accidents, com-
minuted or segmental fracture pattern, ipsilateral bular frac-
ture, and associated orthopaedic injuries are all signi cantly
associated with its development.
Levels of Evidence: Level III—retrospective comparative study.
Key Words: compartment syndrome, pediatric tibial shaft frac-
ture, frequency, risk factors
(J Pediatr Orthop 2020;40:e193–e197)
The diaphysisof thetibia isinvolved in 15% of all pediatric
fractures, making such injuries the third most common
pediatric fracture after those of the femur and forearm.1,2 Im-
portantly, tibial shaft fractures are the most common injuries
associated with acute compartment syndrome (ACS),3–9 em-
phasizing the importance of provider knowledge of the risk
factors and signs and symptoms of ACS in such patients.
Prompt recognition and surgical treatment of this orthopaedic
emergency prevent long-term medical and medical-legal
complications.10–13 Among children and adolescentswith tibial
shaft fractures, the prevalence of subsequent ACS has been
reported to range from 0% for minimally displaced fractures,14
2.4% to 4.8% for open fractures,15–17 12% in the largest study
to datefor thisagegroup (216 fractures in 212 patients),18 and
as high as 19% after exible intramedullary nailing.19 For
comparison, therateof ACSin adultswith tibial shaft fractures
has been reported to be between 4.7% and 17.9%.20–24
Thepurposesof thisstudy wereto determinetherate
at which pediatric patients with tibial shaft fractures de-
velop ACS and to determine if any patient or fracture
From the *Department of Orthopaedic Surgery and Biomedical En-
(1.7%) with 10 (1.9%) fractures developed ACS at a mean age of
15.2 yearscompared with a mean ageof 11 yearsin patientswithout
ACS(P= 0.001). Onepatient with bilateral tibial fracturesdeveloped
ACS bilaterally. Age greater than 14 years (P= 0.006), higher body
mass index (P< 0.001), motorcycle or motor vehicle accidents (P=
0.034), comminuted and segmental tibial shaft fractures (P< 0.001),
ipsilateral bular fracture (P= 0.002), and associated orthopaedic in-
juries (P= 0.032) were all signi cantly more common in the ACS
group.
Conclusions: ACS developed in 1.7% of the patients with tibial
shaft fractures in this retrospective study—a rate signi cantly
factors and signs and symptoms of A
Prompt recognition and surgical treatm
emergency prevent long-term medic
complications.10–13 Amongchildren and
shaft fractures, the prevalence of subse
reported to rangefrom 0%for minimall
2.4% to 4.8% for open fractures,15–17 12
to datefor thisagegroup (216 fractures
as high as 19% after exible intrame
comparison, therateof ACSin adultsw
hasbeen reported to bebetween 4.7% a
Thepurposesof thisstudy were
at which pediatric patients with tibia
velop ACS and to determine if any
characteristics aresigni cantly associ
ACS. Our hypothesiswasthat theinc
lower than reported in previous stud
account a larger population with m
patterns and mechanisms of injury. W
that thelarger samplesizewould pote
that are signi cantly associated with
METHODS
After obtaining IRB approval, a
electronic medical recordsdatabaseusin
diagnosiscodesfor open and closed tib
From the *Department of Orthopaedic Surgery and Biomedical En-
gineering, Le Bonheur Children’s Hospital, University of Tennessee-
Campbell Clinic; and †College of Medicine, University of Tennessee
Health Science Center, Memphis, TN.
No funding was received in support of this study.
D.M.K., D.D.S., and J.R.S. receive publishing royalties from Elsevier.
J.R.S. also receives publishing royalties from Wolters Kluwer.
D.M.K. is a paid speaker for Medtronic and a paid consultant for
WishBoneSurgical. J.R.S. isa paid speaker for DePuy and Nuvasive.
The remaining authors declare no con icts of interest.
Reprints: Benjamin W. Sheffer, MD, Department of Orthopaedic Sur-
gery and Biomedical Engineering, Le Bonheur Children’s Hospital,
University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite
510, Memphis, TN 38104. E-mail: bsheffer@campbellclinic.com.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BPO.0000000000001410
JPediatr Orthop Volume 40, Number 3, March 2020 www.pedorth
Objective
To determine the rate at which acute compartment syndrome (ACS) occurs and if any patient or fracture
characteristics are significant associated with the development of ACS.
Methods
Retrospective, single-center review of all patients aged 5 to 17 years treated for a tibial shaft fracture at a Level I
Pediatric Trauma Center. Data included patient demographics, mechanism of injury, and fracture characteristics.
ACS was diagnosed clinically or by intra-compartmental pressure measurement.
Results
Among 515 patients with tibial shaft fractures, 9 (1.7%) developed ACS at a mean age of 15.2 years compared
with a mean age of 11 years in those without ACS. Factors associated with the development of ACS included:
age >14 years (P=0.006), higher body mass index (P<0.001), vehicular trauma as the mechanism (p=0.034),
comminuted fractures (P<0.001), ipsilateral fibular fracture (P=0.002), and other orthopedic injuries (P=0.032)
Conclusions
ACS developed in 1.7% of patients; a rate that is significantly lower than previously reported. The treating
clinician should recognize specific risk factors for ACS in children with tibial shaft fractures.

18. Overview:
-Patients less than 16 years of age
with tibia shaft fractures were
analyzed in three treatment
groups: cast immobilization,
manipulation under anesthesia, and
surgical intervention
-Patients with multiple fractures
and open fractures were treated
operatively more often with simple
casting.
-Operatively treated patients were
more likely to be older (mean age
13 years), have fibula fractures,
and/or have more primary
angulation on radiographic
imaging

19. CASE #6:
8-year-old presents after falling out of a tree. What do you see?

20. CASE #6:
8-year-old presents after falling out of a tree. Salter-Harris II injury.

21. Resting Zone
Proliferative Zone
Hypertrophic Zone
Calcified Cartilage
The Boney Growth Plate
• Normal bone lengthening
occurs as a result of cellular
proliferation at growth plates.
• All growth plate injuries have
the potential to injure the
activity dividing cells
necessary for normal bone
lengthening.
• More distal growth plate cells
are the most rapidly dividing
(Proliferative Zone).
• For this reason, Salter Harris
injuries involving the distal
growth plate (Type III, IV, V)
are more likely to cause
growth impairment.

22. Separate Separation of the metaphysis and epiphysis Immobile & Ortho F/U
Above Fracture extends into the metaphysis Immobile & Ortho F/U
Lower Fracture through the epiphysis into the joint Ortho Consult In The ED
Through Fracture through the metaphysis, physis, epiphysis Ortho Consult In The ED
CRush Physis and growth chondrocytes are crushed Ortho Consult In The ED
Salter-Harris Classification System

23. CASE #6:
9-year-old with leg pain after a fall. What do you see?

24. CASE #6:
9-year-old with leg pain after a fall. Salter-Harris I injury.

25. CASE #6:
9-year-old with leg pain after a fall. Salter-Harris I injury.

26. CASE #7:
11-year-old presents after a fall. What do you see?

27. CASE #7:
11-year-old presents after a fall. Salter Harris II injury.

28. Lateral View Anterior-Posterior View
Salter Harris II Fracture Of The
Distal Tibia. Note How The
Fracture Extends From The Physis
Into The Metaphysis With
Displacement Laterally.

29. Salter Harris Type II Fracture
Another Example Emphasizing
The Importance Of Obtaining A
Lateral and Anterior-Posterior
View

30. Lateral View Anterior-Posterior View
Salter Harris Type II
Fracture Of The Distal Tibia
With Medial Displacement
And Comminuted Distal
Fibular Fracture With
Angulation

31. Another Example Of Salter Harris
Type II Fracture
Extension Of The
Fracture From
The Physis Into
The Metaphysis.
Key Identifier Of
Salter Harris II
Fractures Is The
Ability Of The
Periosteum To
Remain Intact

32. Objective
To evaluate treatments and outcomes of Salter Harris-II distal tibia fractures.
Methods
Retrospective, single-center review from 2003 to 2017. The following treatment protocol was used:
• Fractures with <3 mm of displacement were treated with a cast
• Fractures with >3 mm of displacement were treated with closed reduction and casting
Results
51 patients (55% female, mean age 9.4 years) were included and followed for at least 4 month. 45 had minimal
displacement and were treated with a cast. Six displaced fractures were treated with closed reduction (mean
displacement 5.7 mm). Outcomes:
• 50/51 (98%) patients had successful fracture healing
• 1/51 (2%) [1/6 (17%) of displaced fractures] had ineffective healing requiring delayed surgery
Conclusions
• Most SH-II tibial fracture are non-displaced and can be managed with casting. Closed reduction should be
performed for displacement >3 mm and if this is ineffective, ORIF should be performed.

33. Toddler’s Fracture
A Toddler’s Fracture Is Defined As A
Non-Displaced Or Minimally
Displaced Tibial Shaft Fracture
With An Intact Tibia.
Spiral Fracture Of Right Tibial Shaft

34. Spiral Fracture Of
The Distal Tibia
Lateral View
Anterior-Posterior View

35. 3-year-old with a twisting injury of the left leg.
Spiral Fracture Of
The Distal Tibia

36. .
2-year-old with right leg pain after a fall.
Spiral Fracture Of
The Distal Tibia

37. Objective
To analyze the outcomes of short versus long leg cases in childhood accidental spiral tibia (CAST) fractures..
Methods
Retrospective, single-center review of children with CAST fractures. Data collected included patient
demographics, type of cast, suspicion of abuse, and complications (skin irritation, skin breakdown, infection,
compartment syndrome, fracture displacement and gait disturbance.
Results
• 21 children ages 12 to 62 months with X-ray confirmed CAST fractures were included.
• 14 children were treated with short-leg casts and 7 were treated with long-leg casts.
• Both groups healed with equal (favorable) outcomes, there were no complications or abuse suspicion
Conclusions
In this study a short-leg cast was effective. This approach may be preferred to long-leg casting because the
inherent increased mobility and function.

38. Summary of This
Month’s Diagnosis
• Salter Harris Tibia Fractures
• Tibia/Fibula Shaft Fractures
• Tibia Spiral Fracture

39. Additional References
• Cepela DJ, Tartaglione JP, Dooley TP, Patel PN. Classifications In Brief: Salter-Harris Classification
of Pediatric Physeal Fractures. Clin Orthop Relat Res. 2016 Nov;474(11):2531-2537. doi:
10.1007/s11999-016-4891-3. Epub 2016 May 20. PMID: 27206505; PMCID: PMC5052189.
• Cruz AI Jr, Raducha JE, Swarup I, Schachne JM, Fabricant PD. Evidence-based update on the
surgical treatment of pediatric tibial shaft fractures. Curr Opin Pediatr. 2019 Feb;31(1):92-102. doi:
10.1097/MOP.0000000000000704. PMID: 30461511.
• Ho CA. Tibia Shaft Fractures in Adolescents: How and When Can They be Managed Successfully
With Cast Treatment? J Pediatr Orthop. 2016 Jun;36 Suppl 1:S15-8. doi:
10.1097/BPO.0000000000000762. PMID: 27078230.
• Kim YC, Jung TD. Peroneal neuropathy after tibio-fibular fracture. Ann Rehabil Med.
2011;35(5):648-657. doi:10.5535/arm.2011.35.5.648
• Stenroos A, Laaksonen T, Nietosvaara N, Jalkanen J, Nietosvaara Y. One in Three of Pediatric Tibia
Shaft Fractures is Currently Treated Operatively: A 6-Year Epidemiological Study in two University
Hospitals in Finland Treatment of Pediatric Tibia Shaft Fractures. Scand J Surg. 2018
Sep;107(3):269-274. doi: 10.1177/1457496917748227. Epub 2018 Jan 1. PMID: 29291697.
• https://www.orthobullets.com/pediatrics/4024/proximal-tibia-epiphyseal-fractures--pediatric
• https://www.orthobullets.com/pediatrics/4026/tibial-shaft-fractures--pediatric