Causes / typical injury mechanism: Tibial shaft fractures in children often occur as a result of low-energy rotational forces on the lower leg, typically due to pivoting or direct trauma with the foot planted, producing isolated tibial fractures with spiral patterns. High-energy trauma may produce transverse fractures (frequently including the fibula), oblique fractures, or comminuted fractures, depending on the axis and magnitude of the forces involved. Particularly high-energy events may result in segmental fractures and extensive soft tissue injury, putting patients at a high risk for compartment syndrome.

Classic history and presentation: Pediatric patients with tibial shaft fractures typically present directly after trauma with visible lower leg deformity and inability to bear weight. Toddlers may present with a limp and refusal to bear weight without a distinguishable traumatic mechanism or limb deformity.

Prevalence:

• Age – Lower leg fractures are most common in patients aged 10-14 years.
• Sex / gender – Pediatric tibial shaft fractures are more common in boys than girls.

Risk factors: While rare, pediatric osteoporosis leads to increased risk of fracture. Primary causes include osteogenesis imperfecta and idiopathic juvenile osteoporosis. A number of secondary causes exist, not limited to chronic malnutrition, chronic inflammation, and endocrine disorders.

Pathophysiology: The tibia is the primary load-bearing bone of the lower leg. Higher-energy mechanisms result in more complex fracture patterns, higher risk of concurrent fibular injury, and increased degrees of soft tissue damage. Axial loading may cause comminuted fractures. Low-energy rotational or torsional force more often results in spiral fractures.

Grade / classification system: Pediatric tibial shaft fractures have no formal classification system and are typically described based on fracture location (proximal, midshaft, distal) and pattern. Common patterns include incomplete (greenstick fractures), complete (transverse, oblique, etc), and spiral fractures (toddler's fracture).