The Case:
A 3-year-old boy slipped on some water and fell to the floor. Since the fall, the child has been crying and won’t put weight on his left leg. On exam, there is increased tenderness upon palpation of the distal portion of the tibia. An xray was performed, shown below:
Click to enlarge
Click to enlarge
Interpretation: An oblique fracture of the distal tibia (known as a toddler’s fracture)
Management: The child was placed in a short leg splint, told to not bear weight, and referred to the orthopedic fracture clinic.
Why it matters:
Toddler’s fractures are nondisplaced spiral or oblique fractures of the lower third of the tibia that occur in young ambulatory children, usually between the ages of 9 months and 3 years. The usual mechanism is a twisting injury while stumbling or falling. Children present limping or refusing to walk and the mechanism is sometimes unknown because it is unwitnessed by parents and the child cannot provide a clear history.
Making matters more challenging, the exam is often difficult and initial radiographs frequently do not reveal an obvious fracture line. Diagnosis may need to be made presumptively.
ED management is somewhat controversial with either an above-knee or below-knee posterior splint. Toddler’s fractures heal quite well without complication, generally within 3-4 weeks. Definitive management seems to be moving away from casting as the most common complication with these injuries is skin breakdown from the cast. Controlled ankle motion (CAM) boots can be used and many patients do not require orthopedic surgeon involvement. Removal of the splint or CAM boot after 3-4 weeks by the family or pediatrician reduces unnecessary radiographs and clinic visits.
Written by Dr. Scott Sherman, MD
Associate Program Director, Cook County Health
References:
Sharieff G. Pediatrics. In Sherman SC (Ed). Simon’s Emergency Orthopedics. McGraw-Hill Education. New York, NY. 2019.
Alqarni N, Goldman RD. Management of Toddler’s Fractures. Canadian Family Physician. Vol 64. Oct 2018. Pgs 740-1.