Most tibial shaft fractures in children can be treated
with closed reduction and cast fixation, but some fractures need external or
internal fixation. The Taylor spatial frame (Smith & Nephew, Memphis,
Tennessee) is a relatively new external fixator that can correct 6-axis
deformities with computer accuracy. This article reports our experience using
the Taylor spatial frame as a rewarding treatment modality for complex tibial
fractures in children and adolescents.
Most tibial shaft fractures in children and adolescents
can be treated with closed reduction and cast fixation; however, some
fractures, especially compound, high-energy displaced fractures and fractures
with delayed union, should be treated with internal or external fixation.
Although rigid intramedullary nailing is widely used with adults, its use with
children is limited because of the presence of open growth plates. External
fixation is the cornerstone treatment for patients with complicated tibial
fractures, severe soft tissue damage, and multiple trauma. Monolateral or
circular external fixators can be employed in their treatment. While
monolateral fixators are easy to assemble, they are usually less stable than
circular fixators, and difficult or even impossible to adjust
The Ilizarov device is the classic example of a circular
external fixator.3,4 The introduction of this device and its method
dramatically changed our understanding of deformities and fractures and our
ability to manage them. However, despite its obvious advantages, many surgeons
experience difficulty with its application and with mastering
The Taylor spatial frame (Smith & Nephew, Memphis,
Tennessee) is a relatively new external fixator. This unique, stable device is
able to correct 6-axis deformities with computer accuracy. This article reports
our experience with using the Taylor spatial frame in the treatment of complex
tibial fractures in children and adolescents.
Materials and Methods
From March 2003 to July 2006, 13 patients with
complicated tibial fractures were treated using the Taylor spatial frame. The
study group comprised 12 boys and 1 girl with a mean age of 11.1 years (range,
5-16 years) at the time of frame application. Nine fractures were open and 4
were closed. The 9 open fractures were graded as Gustilo grade II (4
fractures), grade IIIA (2 fractures), and grade IIIB (2 fractures). Eight
patients had associated injuries (Table). There were 2 fractures of the distal
tibia, 1 proximal, and 10 midshaft.
Prior to application of the Taylor spatial frame, all
patients were treated with another fixation method. All patients with open
fractures, except 1, initially underwent debridement and primary stabilization
with a unilateral external fixator. Closed fractures were treated initially
with closed reduction and cast fixation. One patient with a closed distal
tibial fracture developed compartment syndrome and underwent a 4-compartment
fasciotomy and application of an Ilizarov fixator. Mean time interval from
fracture to Taylor spatial frame application was 31.8 days (range, 3-165 days).
The indications for Taylor spatial frame exchange were unacceptable alignment
in cast or external fixator in 11 patients and nonunion or delayed union in 2.
The basic principles of the Taylor spatial frame are
well described.1,5-8 Deformity parameters showing relationships
between origin and corresponding point were determined using the fracture
method.5,6 Frame parameters reflected the relationship between ring
diameters and strut length, while mounting parameters reflected distance
between origin and center of the reference ring. The reference ring was applied
strictly orthogonal to the reference fragment, which was either proximal or
distal (Figure 1A). The second ring on the moving fragment can be applied in a
nonorthogonal position relative to the fragment. Care is needed to prevent a
rotary frame offset, but if offset is already present it should be accurately
determined and noted in the report (Figure 1B). After frame application,
full-leg radiographs were taken in the operating room. For accurate
determination of deformity and mounting parameters, the center of the reference
ring was marked on AP and lateral views. We did not try to reduce the fracture
acutely. The total residual program was employed in all patients, and
correction was begun 1 day postoperatively.
|Figure 1: Fixation of the distal reference ring. Note that this ring should be strictly orthogonal to the reference fragment and parallel to the ankle joint (A). Typical pin and wire placement in a mid-diaphyseal fracture of the tibia. In this case distal reference was chosen. Note zero rotational offset (B). Figure 2: AP view of delayed union 11 weeks after open fracture of the open mid-tibia and fibula (A). Lateral view (B). Immediate AP (C) and lateral (D) postoperative radiographs. AP (E) and lateral (F) radiographs after frame removal.
All fractures except 1 were united in normal anatomical
alignment and frames were removed. Mechanical axis deviation was minimal or
negligible compared to the contralateral limb. At latest follow-up, mean medial
proximal tibial angle was 88° (range, 85°-89°), mean posterior
proximal tibial angle was 81° (range, 79°-83°), and mean lateral
distal tibial angle was 90° (range, 88°-93°). Mean time of frame
fixation was 11 weeks (range, 7-18 weeks). All deformities were corrected
gradually (velocity correction of 1 mm daily). One patient had a mild
restriction of knee movement, which resolved a few weeks after frame removal.
All other patients had no significant restriction of knee and ankle movement
during fixation. Complications were related to superficial pin tract infections
in 5 patients, which resolved after a short course of oral antibiotics. One
patient, after a lengthening of 40 mm (Figures 2, 3), developed a proximal
tibial valgus 1 year after frame removal, which was addressed with medial
Most pediatric tibial fractures can be successfully
treated with closed reduction and cast fixation; however, there are several
indications for surgical treatment, including tibial fractures that cannot be
maintained in a reduced position in a cast, open fractures, multiple trauma
(especially in older children), fractures associated with compartment syndrome,
and floating knees.9
Rigid intramedullary nailing is impractical due to the
presence of the growth plates and the relatively short length of the tibia in
children. External fixation is the mainstay treatment of severely comminuted
open fractures with soft-tissue injury and unstable tibial
fractures.2,10-12 Several external fixators are available. For
simple fractures, a monolateral external fixator can be a good solution, but
for many complex tibial fractures, circular external fixators offer better
stability and the ability to correct the deformity gradually. The Ilizarov
frame is the classic option, but the reduction technique, especially when
multiplanar correction is needed, is difficult to perform with the Ilizarov
|Figure 3: Gustilo IIIB open fracture of the tibia in a 10-year-old boy (A). Clinical photographs of the leg (B). Radiographs showing a 40-mm gap after removal of all nonviable bone spikes (C). Acute shortening and posterior angulation (D). Clinical appearance of the leg after shortening and angulation (E). AP (F) and lateral (G) radiographs after proximal tibial osteotomy and 40 mm lengthening. Final radiographs 18 months after removal showing proximal tibial valgus treated with medial proximal tibial hemiepiphysiodesis (H).|
The Taylor spatial frame is stable and possesses the
unique advantage of allowing 6-axis deformity correction with computer
accuracy.5 We found relatively few examples in the literature on the
use of the Taylor spatial frame in fracture care.1,8,13-15
Binski1 reviewed results of fixation of acute tibial fractures in
adult patients. He achieved a 93% union rate, with 96% anatomical alignment of
the mechanical axis. Only 3 patients underwent a second operation due to
nonunion and refracture. The author concluded that the Taylor spatial frame is
an effective tool and can be used as definitive method for fracture care using
an external fixator.
Only 1 article described the use of the Taylor spatial
frame in the treatment of pediatric tibial fractures: Al-Sayyad13
reported the results of the treatment of 10 tibial fractures in 9 children with
an average age of 12 years. He reduced all fractures acutely with
fine-tuning a few days postoperatively.
Feldman et al14 achieved union and deformity
correction in 17 of 18 patients with post-traumatic tibial malunion and
The Taylor spatial frames ability to correct
6-axis deformities precludes the need for frame adjustments, which are usually
needed with the Ilizarov fixator. In addition, reduction can be performed
gradually at any time postoperatively and after optimal care of the soft
The majority of our patients were treated with the
Taylor spatial frame after considerable delay following fracture (mean, 31.8
days; range, 3-165 days). Acute anatomical reduction in this situation is
difficult and often impossible to perform. Gradual reduction in children should
be performed in all cases when fracture reduction is significantly delayed,
because acute reduction in such a situation will cause unnecessary pain. The
Taylor spatial frame is an ideally fitted device for controlled gradual
reduction to prevent neurovascular compromise and skin and soft tissue
problems. The mean age of our patients was 11.1 years, when growth stimulation
and remodeling potential relatively decrease.16 After the age of 10,
acceptable reduction of tibial fractures is quite close to adults
criteria, with no malrotations acceptable.
The orthogonal position of the reference ring relative
to the reference fragment is important for accurate measurement of the Taylor
spatial frames parameters. Any residual correction and fine-tuning of
fracture reduction can be performed in the office without frame modification
(Figure 3). The current high cost of Taylor spatial frame equipment restricts
its wide use in practice, but its obvious advantages will help it become the
external fixation of choice in many centers.
Based on our experience, we believe that the Taylor
spatial frame is a fixator with outstanding stability and computer accuracy.
The Taylor spatial frame is our treatment of choice for complex displaced
tibial fractures in children and adolescents.
- Binski JC. Taylor spatial frame in acute fracture care. Tech
Orthop. 2002; 17(2):173-184.
- Norman D, Peskin B, Ehrenraich A, Rosenberg N, Bar-Joseph G, Bialik
V. The use of external fixators in the immobilization of pediatric fractures.
Arch Orthop Trauma Surg. 2002; 122(7):379-382.
- Ilizarov GA. Transosseous Osteosynthesis: Theoretical and Clinical
Aspects of the Regeneration and Growth of Tissue. Berlin, Germany:
- Solomin LN. General Aspects of Transosseous Osteosynthesis by
Ilizarov Apparatus [in Russian]. St Petersburg, Russia: Morsar; 2005.
- Taylor JC. Correction of general deformity with Taylor spatial frame
fixator. J Charles Taylor, MD, Web site.
http://www.jcharlestaylor.com/spat/00spat.html. Accessed June 2008.
- Taylor JC. Six-axis deformity analysis and correction. In: Paley D,
ed. Principles of Deformity Correction. New York, NY: Springer-Verlag;
- Rozbruch SR, Fragomen AT, Ilizarov S. Correction of tibial deformity
with use of the Ilizarov-Taylor spatial frame. J Bone Joint Surg Am.
2006; 88(suppl 4):156-174.
- Eidelman M, Bialik V, Katzman A. Correction of deformities in
children using the Taylor spatial frame. J Pediatr Orthop B. 2006;
- Rang M, Wenger DR, Pring ME. Rangs Childrens
Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;
- Cramer KE, Limbird TJ, Green NE. Open fractures of the diaphysis of
the lower extremity in children. Treatment, results, and complications. J
Bone Joint Surg Am. 1992; 74(2):218-232.
- Kreder HJ, Armstrong P. A review of open tibia fractures in children.
J Pediatr Orthop. 1995; 15(4):482-488.
- Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in
children and adolescents. Am Acad Orthop Surg. 2005; 13(5):345-352.
- Al-Sayyad MJ. Taylor Spatial Frame in the treatment of pediatric and
adolescent tibial shaft fractures. J Pediatr Orthop. 2006;
- Feldman DS, Shin SS, Madan S, Koval KJ. Correction of tibial malunion
and nonunion with six-axis analysis deformity correction using the Taylor
Spatial Frame. J Orthop Trauma. 2003; 17(8):549-554.
- Seide K, Wolter D, Kortmann HR. Fracture reduction and deformity
correction with hexapod Ilizarov fixator. Clin Orthop Relat Res. 1999;
- Von Laer L. Pediatric Fractures and Dislocations. New York,
NY: Thieme Medical Publishers; 2004.
Drs Eidelman and Katzman are from the Pediatric
Orthopedic Unit, Meyer Childrens Hospital, Rambam Medical Center, Haifa,
Drs Eidelman and Katzman have no relevant financial
relationships to disclose.
Correspondence should be addressed to: Mark Eidelman,
MD, Pediatric Orthopedic Unit, Meyer Childrens Hospital, Rambam Health
Care Campus, Aalia St 6, Bat-Galim, PO Box 96092, Haifa 31096, Israel.