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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 95-97

Diaphyseal depression fracture of the tibia by a cricket ball in a child: A probable first report of rare injury

Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission05-Apr-2020
Date of Acceptance08-Jun-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JODP.JODP_11_20

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Undescribed fracture patterns are rare presentations in fracture clinics and are mostly limited to a few reports in the literature if any. The pediatric diaphyseal fractures of the tibia usually follow common described patterns, such as transverse, spiral, oblique, or comminuted configuration. Depression fractures, though well described at the articular region such as tibial plateau, are not found at diaphyseal sites. The localized saucer-shaped depression fracture in the diaphysis thus is an undescribed injury. We present a rare report of an isolated, unicortical, and localized depression fracture of the tibial diaphysis in a 10-year-old child following hit by a cricket ball during the match. He was managed conservatively with good functional outcome. Knowledge of this rare pattern of injury is helpful to acknowledge its occurrence and its listing in scientific literature.

Keywords: Child, cricket, fracture, injury, sports, tibia, treatment

How to cite this article:
Mourya P, Dharmshaktu GS. Diaphyseal depression fracture of the tibia by a cricket ball in a child: A probable first report of rare injury. J Orthop Dis Traumatol 2020;3:95-7

How to cite this URL:
Mourya P, Dharmshaktu GS. Diaphyseal depression fracture of the tibia by a cricket ball in a child: A probable first report of rare injury. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Oct 30];3:95-7. Available from: https://www.jodt.org/text.asp?2020/3/2/95/294725

  Introduction Top

Fractures involving bones of the leg are common injuries in children and only preceded by forearm and femur fractures in the prevalence. The injury constitutes approximately 15% of pediatric long bone trauma.[1],[2] The majority of pediatric tibial shaft fractures are short oblique or transverse and spiral.[2] Mostly, tibia fractures are isolated with only less than third cases have associated fibula fracture.[3],[4] Distal third of the tibia is the common site of fractures in older children and adolescents. Majority of the isolated tibia fractures are related to rotational injuries and subsequently present with oblique or spiral pattern.[2],[4],[5] The road traffic accidents and sports injuries are the common mode of injuries in older and adolescent age group. While fibula has been associated with direct blow injury, the tibia is less associated with this. The depression fracture has been described in the tibial plateau region fracture of adults, but not in children. The localized depression fracture of the long bone diaphysis is also not described. Our case with depression fracture of the tibia diaphysis following direct blow is a rare injury and has not been mentioned in the contemporary literature, to the best of authors' knowledge.

  Case Report Top

A 10-year-old male child was brought to us with a history of fall of a cricket ball from height during the match into his left leg a few hours back. The curved edge of the cricket ball hit the leg before falling to the ground. There were pain and disability to weight-bearing, and he was brought to us piggybacked. The downward hard ball through a projectile height hit the leg, and there was a soft tissue contusion at the site of impact corresponding to the size and shape of ball. There were mild superficial contusion and abrasion, with visible localized depressed bone. There was no associated injury elsewhere, and knee and ankle movement of injured lower extremity was normal. The wound was cleaned and dressed before prescribing the appropriate radiographs.

The radiograph of the leg in the orthogonal plane showed a well-defined localized area of depressed fracture in the diaphysis of tibia at junction of the middle and lower third of the bone [Figure 1]. The depressed part was comminuted with no bone loss to the outside. The unicortical injury at the medial aspect was associated with intact fibula. The adjacent knee and ankle joints were normal. This fracture appearance was unusual and was corresponding to the history of injury.
Figure 1: The radiograph of the injured leg showing the unicortical localized saucer-shaped depressed fracture of tibia diaphysis

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The parents were advised conservative management in view of stable nature of the injury, initially managed with above knee plaster slab to accommodate for probable tissue edema. The wound dressing (only two required) was done with cutting a window through slab. Later conversion to plaster cast was done after 10 days, and wound was healed in the meantime [Figure 2]. The plaster cast was applied in functional brace manner to promote early recovery and avoid knee stiffness. The follow-up was done every 3rd day at initial month and then at 4, 6, 12, and 24 weeks. The final follow-up at 12 and 18 months showed complete attainment of preinjury level of function and healed fracture.
Figure 2: The clinical picture showing healed skin contusion wound

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There were uneventful wound and bone healing noted on clinic-radiological follow-up. The fracture united well with regain of localized bone in the 8th week-time [Figure 3]. There was no functional deficit noted, and the patient was performing activities of daily living. There was no complication related to the wound after healing. There was no related or remote complication in a follow-up of 18 months.
Figure 3: The radiograph showing healed injury at 8-month follow-up

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  Discussion Top

Direct trauma has been associated with most of the comminuted tibia fracture. Our fracture was unicortical with intact fibula; thus, length was maintained with minimal clinical deformity and instability. Had it been a complete fracture, a varus malalignment would have resulted leading to residual deformity and other related future complications if not managed.[3] The localized depression with minimal periosteal injury has good healing potential and just required rest and protection for healing. The majority of tibia fractures have been treated successfully with conservative treatment.[6] Displacement of fracture, which in our case was improbable, leads to suboptimal outcome and needs regular radiological assessment. The fracture location and age are the criteria other than degree of deformity in the estimation of appropriate alignment.[7] Our case with length maintained fracture without displacement has good prognostic factor despite mild superficial skin and soft tissue contusion. Retained periosteum and comminution was also contributory to early and good union. Operative treatment, for cases of failed attainment or retention of closed reduction, with various modalities including flexible nails, has recently gained popularity for being minimal invasive and effective.[8] Only one report of muscle hernia as a result of cricket ball injury was found, and the case was managed by limited fasciotomy.[9] A common injury in the pediatric skull and depression fractures in the long bones are underreported in the literature, and lack of similar injury in the literature is unavailable.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hansen BA, Greiff S, Bergmann F. Fractures of the tibia in children. Acta Orthop Scand 1976;47:448-53.  Back to cited text no. 1
Shannak AO. Tibial fractures in children: Follow-up study. J Pediatr Orthop 1988;8:306-10.  Back to cited text no. 2
Yang JP, Letts RM. Isolated fractures of the tibia with intact fibula in children: A review of 95 patients. J Pediatr Orthop 1997;17:347-51.  Back to cited text no. 3
Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: A study of 3,350 children. J Orthop Trauma 1993;7:15-22.  Back to cited text no. 4
Mellick LB, Milker L, Egsieker E. Childhood accidental spiral tibial (CAST) fractures. Pediatr Emerg Care 1999;15:307-9.  Back to cited text no. 5
Holderman WD. Results following conservative treatment of fractures of the tibial shaft. Am J Surg 1959;98:593-7.  Back to cited text no. 6
Dwyer AJ, John B, Krishen M, Hora R. Remodeling of tibial fractures in children younger than 12 years. Orthopedics 2007;30:393-6.  Back to cited text no. 7
Srivastava AK, Mehlman CT, Wall EJ, Do TT. Elastic stable intramedullary nailing of tibial shaft fractures in children. J Pediatr Orthop 2008;28:152-8.  Back to cited text no. 8
Gupta RK, Singh D, Kansay R, Singh H. Cricket ball injury: A cause of symptomatic muscle hernia of the leg. Br J Sports Med 2008;42:1002-3.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]


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