Updated German National S1 Guideline on Pediatric Lower Leg Shaft Fractures

Abstract

Fractures of the diaphysis of the lower leg account for approximately 6% of all fractures in children and adolescents. A distinction must be made between isolated tibial shaft fractures, which are primarily managed conservatively, and combined lower leg shaft fractures (involving both the tibia and fibula). The latter are significantly less stable and therefore more frequently treated with osteosynthesis. If the fracture is non-displaced or tolerably displaced, immobilization in a long leg cast for about 4 weeks is sufficient. This requires that no secondary displacement occurs within the cast, which is why at least one follow-up X-ray after about 7–10 days is mandatory. In cases of instability, non-tolerable displacement, open fractures, or (impending) compartment syndrome, surgical treatment is indicated. The elastic stable intramedullary nailing (ESIN) technique is the standard procedure in these cases due to its low risk profile, broad applicability, minimally invasive approach, and good functional outcomes. After ESIN osteosynthesis, immobilization in a cast is not necessary. Other osteosynthesis methods, such as external fixation or plate osteosynthesis, are reserved for special cases like grade III open fractures, refractures, or comminuted fractures. The prognosis for tibial and lower leg shaft fractures in children is very good when conservative or surgical therapy is carried out correctly. Complications such as compartment syndrome, pseudarthrosis, or clinically relevant leg length discrepancies are rare. It is important to be familiar with the age-dependent tolerance limits for remodeling of the lower leg shaft, so that in the event of failure of conservative therapy, the indication for surgical treatment can be made in a timely manner and permanent malalignment of the lower leg with resulting abnormal loading of the knee and ankle joints can be avoided.
An important and common special form is the so-called toddler’s fracture, which occurs exclusively in early childhood. This involves a subtle, non-displaced spiral fracture or fissure of the tibial shaft, typically caused by a minor fall, often with a rotational component. These fractures can be easily missed on initial X-ray diagnostics. Immobilization for pain relief is sufficient, and follow-up radiological examinations are generally not necessary.

Keywords

lower leg shaft fracture - tibial shaft fracture - lower leg fracture - elastic stable intramedullary nailing - long leg cast

Publication History

Received: 07 October 2025

Accepted after revision: 02 December 2025

Article published online:
26 February 2026

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