Toddler fracture

Aila, a 2-year-old girl, presents to the emergency department with her mother. She had been running around at childcare, playing with her friends, when she fell over. She is upset, has refused to walk since, and won’t bear weight on her right leg.

On examination, there is no noticeable swelling or deformity. On palpation and axial loading, it appears that her pain is most likely localised to her right lower leg, but it’s hard to be sure.

A toddler’s fracture is a non-displaced spiral fracture of the distal two-thirds of the tibial shaft, with an intact fibula, occurring in children generally between the ages of 9 months and three years. The periosteum remains intact. It was first described in 1964 by Dunbar et al. It is thought to be due to new stresses on the bone due to increasing ambulation.

History and examination

The mechanism is usually trivial, such as a trip or a fall, and often involves a twisting motion. Sometimes, eliciting a specific story of trauma can be challenging. More commonly, children are unwilling to bear weight or limp with non-specific examination findings. They may be tender to palpation of the tibia, experience pain with dorsiflexion of the ankle, or feel pain with gentle twisting of the lower leg. All joints of the lower limb should be examined. It is always worth examining both lower limbs, as gait can be challenging to assess in toddlers and may be misleading regarding the side of the injury.

As part of a thorough history and examination, any history of fever, weight loss, recent illness, or recurrent presentations with minor injuries should be elicited. Additionally, the child should undergo a thorough examination of their spine and neurology, as well as a detailed assessment for any bruising, petechiae, warmth, swelling of joints, and puncture wounds on the soles of the feet.

Imaging

Initial X-rays may show a non-displaced spiral fracture of the tibia. However, a fracture may only be seen in multiple views. AP and lateral views should be adequate in children. An oblique view may help. A repeat X-ray in one week typically reveals sclerosis or a periosteal reaction. 

But, a plain film X-ray may not be where it ends. Ultrasound is being explored as a possible diagnostic tool for toddler’s fracture, as sonography is used more and more for the diagnosis of long bone fractures in children. The idea’s not a new one; a case report of three children in England in 2006 demonstrated that Point of Care Ultrasound Scan (POCUS) could be used to diagnose toddler’s fracture where initial x-rays did not show any fractures. They used the appearance of an elevated periosteum and a layer of low reflectivity superficial to the tibial cortex, which suggests a fracture haematoma, as a way of diagnosing an occult fracture. 

A recent pilot study by Carsen et al., comparing ultrasound with radiographic diagnosis of toddler fractures, examined 27 children presenting with suspected toddler fractures. Five children had confirmed toddler fractures, and three were identified correctly by X-ray at the initial presentation. The other two were diagnosed with repeat X-ray at follow-up appointments. All five children had their toddlers’ fractures correctly identified using POCUS at their initial presentation. 

Although limited studies evaluate the use of POCUS in the diagnosis of toddler fractures, the small number of studies and case studies available is promising. Furthermore, as a point-of-care test in someone with appropriate training, this is a convenient diagnostic tool, particularly given the potential to reduce radiation exposure for children.

How do we manage a Toddler fracture?

Toddlers’ fractures do not require reduction, and management is primarily supportive for 3-4 weeks. The standard treatment is a long leg back slab followed by a long leg walking cast. 

Several retrospective studies have examined rates of immobilising toddlers’ fractures when the diagnosis is confirmed or presumed. They show that children with confirmed toddler fractures are more likely to be immobilised.

But… a series of 75 children with radiographic evidence of toddlers’ fractures, as studied by Schuh et al., examined outcomes following various treatments, including cast/splint, controlled ankle movement boot, or no immobilisation. Those not immobilised had fewer follow-up appointments and fewer repeat radiographs. Skin breakdown was reported in 17% of children, all of whom were in a splint or cast. Schuh et al. also found that children not immobilised walked much earlier than those immobilised in a controlled ankle movement (CAM) boot or splint. The mean time to recovery was 4.1 days for the little ones who were not immobilised, compared to 27.0 days for those in a boot and a whopping 27.5 days for those in a cast or splint.  

Another retrospective study by Bauer and Lovejoy of 192 children aged 9 months to 4 years, meeting the criteria for a toddler’s fracture, showed an earlier return to weight-bearing in those immobilised with a CAM boot compared with a short-leg cast (2.5 vs. 2.8 weeks). Even when considering the seven children in this study who received no immobilisation, none of the fractures shifted. Sapru and Cooper also found no complications with management in or out of a cast.  

There is now a trend towards recommending immobilisation in a CAM boot, short-leg cast, or splint rather than in a long-leg cast. Further studies are currently underway, so watch this space!

What not to miss

A thorough history and examination should always be conducted to avoid missing other potential diagnoses. If a child is not yet mobile, there must be a high suspicion of non-accidental injury. Fevers warrant consideration of septic arthritis or osteomyelitis. Malignancy and inflammatory conditions should also be considered. 

Aila’s initial x-ray showed a non-displaced spiral fracture of the distal third of her right tibia. She was placed in a long leg back slab and had a follow-up with the local orthopaedic service in the fracture clinic. Four weeks later, she is running around and happily playing with her older brother.

References

Alqarni, N., & Goldman, R. D. (2018). Management of toddler’s fractures. Canadian family physician Medecin de famille canadien, 64(10), 740–741. 

Bauer, J.M., Lovejoy, S.A. (2019) Toddler’s Fractures: Time to Weight-bear with Regard to Immobilization Type and Radiographic Monitoring. J Pediatr Orthop. Jul: 39(6), 314-317. 

Carsen, S., Doyle, M., Smit, K., Shefrin, A., Varshney, T. (2020) Point-of-care Ultrasound in the Emergency Department may provide more accurate diagnosis of toddler fractures than radiographs: A pilot study. Orthopaedic Proceedings. 102-B

Dunbar, J.S., Owen, H.F., Nogrady, M.B., McLeese, R., (1964) Obscure Tibial Fracture of Infants – The Toddler’s Fracture. Journal of the Canadian Association of Radiologists, Sep;15, 136-144. 

Fox, S. (2013) Toddler’s Fracture. Available at: https://pedemmorsels.com/toddlers-fracture/

Lewis, D. and Logan, P. (2006), Sonographic diagnosis of toddler’s fracture in the emergency department. J. Clin. Ultrasound. 34: 190-194. 

Pattishall, A.E. (2019) An updated approach to toddler fractures. J Urgent Care Med.  Available at: https://www.jucm.com/an-updated-approach-to-toddler-fractures/

Rasuli, B., Gaillard, F. Toddler Fracture. Available at: https://radiopaedia.org/articles/toddler-fracture

Royal Children’s Hospital Guidelines – Tibial Shaft Fractures. Available at: https://www.rch.org.au/clinicalguide/guideline_index/fractures/tibial_shaft_emergency/

Sapru, K., Cooper, J.G. (2014). Management of the Toddler’s fracture with and without initial radiological evidence. Eur J Emerg Med. Dec;21(6), 451-454. 

Schuh, A.M., Whitlock, K.B., Klein, E.J. (2016) Management of Toddler’s Fractures in the Pediatric Emergency Department. Pediatri Emerg Care.  Jul: 32(7), 452-454.

UpToDate – Tibial and fibular shaft fractures in children

Wang, C.C., Linden, K.L., Otero, H.J. (2017) Sonographic Evaluation of Fractures in Children. Journal of Diagnostic Medical Sonography. 33(3), 200-207. 

Wijtzes, N., Jacob, H., Knight, K., Thrust, S., Hann, G. (2020) Fifteen-minute consultation: The toddler’s fracture. Arch Dis Child Educ Pract Ed. 0, 1-6.