Remodeling of Pediatric Tibial Shaft Fractures: What Should We Expect?

While the majority of tibial shaft fractures in pediatric patients are managed nonoperatively with closed reduction and casting, it is unknown how much remodeling occurs in young patients. We hypothesize that younger children would exhibit greater remodeling and lower residual angulation compared to older children 6 months post-injury. Patients under age 17 years at a major pediatric health system with ICD-9 or ICD-10 codes for closed tibial shaft fractures between January 2009 and August 2023 were included. Patients with radiographs at baseline and 6-month follow-up were eligible. Exclusion criteria were operatively managed, open, or comminuted fractures; re-fractures; history of malignancy or metabolic diseases; or lack of imaging. Radiographs post-reduction and at 6 months were reviewed to assess translation, angulation, shortening, and remodeling in the coronal and sagittal planes. Differences in baseline and follow-up measurements were compared between children under age 8 and aged 8-16 years. 38 patients (14 female) were included with an average age of 7.3 years (Range 1 year to 14 years). Baseline translation for younger patients was 13.5%±18.1% and 15.1%±13.7% in the coronal and sagittal plane, respectively; baseline translation for the older cohort was 20.9%±13.5 and 24.1±17.3% for the coronal and sagittal plane, respectively. All patients demonstrated complete correction of fracture translation in both planes at 6 months post-injury (p < 0.001). While coronal plane remodeling was not significantly different between age groups, the younger cohort exhibited significant sagittal plane remodeling at 6 months compared to baseline (2.68° vs. 1.27°, p < 0.01). Younger patients also had significantly lower residual angulation in the coronal (1.31° vs. 2.38°, p < 0.05) and sagittal (1.27° vs. 3.38°, p < 0.05) planes at 6 months compared to the older cohort. Tibial shaft fracture translation resolves over 6 months for all pediatric patients. Younger children tend to have less residual angulation and more remodeling, particularly in the sagittal plane. Our findings suggest more attention is needed to minimize coronal angulation following tibial shaft fractures in pediatric patients. Level III: Retrospective cohort study • Pediatric tibial shaft fractures demonstrate substantial remodeling capacity, with all study patients showing complete correction of fracture translation and shortening within six months of non-operative treatment. • Non-operative management remains an effective and reliable treatment strategy for appropriately selected pediatric tibial shaft fractures. • Younger children exhibit significantly greater remodeling potential, particularly in the sagittal plane, resulting in lower residual angulation compared to older children. • Age-related differences in remodeling support individualized treatment approaches.