BACKGROUND: Many orthopaedic surgeons treat tibial shaft fractures in children with a period of non-weight-bearing after application of a long leg cast, presumably to prevent fracture angulation and shortening. We hypothesized that allowing children to immediately bear weight as tolerated in a cast with the knee in 10 degrees of flexion would lessen disability, without increasing the risk of unacceptable shortening or angulation. METHODS: We divided eighty-one children, between the ages of four and fourteen years, with a low-energy, closed tibial shaft fracture into two groups. One group (forty children) received a long leg cast with the knee flexed 60 degrees and were asked not to bear weight. The second group (forty-one children) received a long leg cast with the knee flexed 10 degrees and were encouraged to bear weight as tolerated. All patients were switched to short leg walking casts at four weeks. We compared time to healing, overall alignment, shortening, and physical disability as determined by the Activities Scale for Kids-Performance (ASK-P) questionnaire. RESULTS: The mean time to fracture union was 10.8 weeks in both groups (p = 0.47). At the time of healing, mean coronal alignment was within 1.3 degrees in both groups, mean sagittal alignment was within 1 degree, and mean shortening was < 0.5 mm, with no significant differences. The ASK-P scores showed that both groups had overall improvement in physical functioning over time. However, at six weeks, the children who were allowed to bear weight as tolerated had better overall scores (p = 0.03) and better standing skills (p = 0.01) than those who were initially instructed to be non-weight-bearing. CONCLUSIONS: Children with low-energy tibial shaft fractures can be successfully managed by immobilizing the knee in 10 degrees of flexion and encouraging early weight-bearing, without affecting the time to union or increasing the risk of angulation and shortening at the fracture site. LEVEL OF EVIDENCE: Therapeutic level II.

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