A mother and father bring their 2-year-old boy to the Emergency Department after the child tripped over the family dog while running across the living room after a ball. He will not walk and points at his right lower leg and says it hurts (photo credit).
This is a radiographically subtle nondisplaced spiral fracture of the tibia in a child less than 3 years of age, also known as a toddler’s fracture or childhood accidental spiral tibia (CAST) fracture.
Initial radiographs in patients with suspected toddler’s fracture have been reported to be negative up 59–66% of the time.1,2 Ultrasound has been described in a small number of cases to identify toddler’s fracture when initial radiographs were negative, but there is limited data to recommend routine use of this imaging modality.3
If this injury is clinically suspected, you should treat the patient as though the injury is present, even with negative imaging.2
- Inability to bear weight on the affected limb is the most sensitive physical exam finding. Sensitivities range from 85–95%, although it is nonspecific.4,5
- Isolated tenderness to palpation over the tibia is less sensitive (71%) and remains relatively non-specific (67%).1
- Pain may be elicited with ankle dorsiflexion and rotation.
The injury generally occurs by a seemingly benign, low impact, rotational mechanism. The most common mechanism of injury is a witnessed fall.1
Traditional management suggests placement in a posterior leg splint and then long leg casting. However, studies suggest that placing the patient in a controlled-ankle motion (CAM) walking boot will have similar outcomes and fewer complications compared to traditional splints and casts.6-9 For emergency departments that do not have access to pediatric CAM walking boots, a reasonable option is a posterior slab splint with instructions for the parents to purchase a CAM walking boot. These are readily available on Amazon: Premium Cam Walker Boot and Short Pneumatic Walker Boot. Consider the reliability of the patient and family and engage in an informed discussion with the parents.
Discharge home under the care of the patient’s guardians.
If fracture is confirmed, parents may follow-up with their PCP, remove the boot at home in 3-4 weeks, and should follow up with orthopedics with persistent symptoms.10 Prolonged immobilization can result in increased risk of complications.
If a fracture is not radiographically confirmed, the patient should follow-up with orthopedics in 7-10 days.
A toddler’s fracture is not typically caused by non-accidental trauma, thus routine CPS reporting is not necessary.1,11 It is important to note that over 90% of reported toddler’s fractures in the literature have a known mechanism of injury, thus the absence of a history consistent with the pattern of injury should prompt further consideration for non-accidental trauma.1
For more cases like these, you can check out the SplintER series archive or subscribe to the Ortho EM Pearls email series hosted by Drs. Will Denq, Tabitha Ford, and Megan French, who have kindly shared some of their content with ALiEM.
References
- Halsey MF, Finzel KC, Carrion WV, Haralabatos SS, Gruber MA, Meinhard BP. Toddler’s fracture: presumptive diagnosis and treatment. J Pediatr Orthop. 2001;21(2):152–6. PMID: 11242240
- Sapru K, Cooper JG. Management of the toddler’s fracture with and without initial radiological evidence. Eur J Emerg Med. 2014;21(6):451–4. PMID: 24802106
- Lewis D, Logan P. Sonographic diagnosis of toddler’s fracture in the emergency department. J Clin Ultrasound. 2006;34(4):190–4. PMID: 16615049
- Shravat BP, Harrop SN, Kane TP. Toddler’s fracture. J Accid Emerg Med. 1996;13(1):59–61. PMID: 8821231
- Tenenbein M, Reed MH, Black GB. The toddler’s fracture revisited. Am J Emerg Med. 1990;8(3):208–11. PMID: 2331262
- Seguin J, Brody D, Li P. Nationwide survey on current management strategies of toddler’s fractures. CJEM. 2018;20(5):739-45. PMID: 28743319
- Bauer JM, Lovejoy SA. Toddler’s fractures: time to weight-bear with regard to immobilization type and radiographic monitoring. J Pediatr Orthop. 2017. Epub ahead of print. PMID: 28141694
- Houlden R. Does immobilisation improve outcomes in children with a toddler’s fracture? Arch Dis Child. 2019;104(2):193-95. PMID: 30297443
- Schuh AM, Whitlock KB, Klein EJ. Management of toddler’s fractures in the pediatric emergency department. Pediatr Emerg Care. 2016;32(7):452–4. PMID: 26087443
- Adamich JS, Camp MW. Do toddler’s fractures of the tibia require evaluation and management by an orthopaedic surgeon routinely? Eur J Emerg Med. 2018;25(6):423-428. PMID: 28628487
- Mellick LB, Reesor K. Spiral tibial fractures of children: a commonly accidental spiral long bone fracture. Am J Emerg Med. 1990;8(3):234–7.PMID: 2331264
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