A 2-year-old girl, Aila, 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 weight bear on her right leg. On examination, there is no obvious swelling or deformity and 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 3 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, a trip or a fall, and often involves a twisting mechanism. Sometimes a specific story of trauma is difficult to elicit. More commonly children present unwilling to bear weight or limping with non-specific examination findings. They may be tender to palpation of the tibia, have pain with dorsiflexion of the ankle or 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 difficult 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. The child should have their spine and neurology examined as well as any bruising, petechiae, warmth and swelling of joints, and puncture wounds on the soles of the feet documented.
Initial x-rays may show a non-displaced spiral fracture of the tibia, however, a fracture may not be seen despite multiple views. AP and lateral views should be adequate in children, however, an oblique view may help. A repeat x-ray in 1 week usually shows sclerosis or 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 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 to radiographic diagnosis of toddler’s fractures looked at 27 children presenting with suspected toddler’s fractures. Five children had confirmed toddler’s fractures and of these five, three were identified correctly by x-ray at initial presentation and the other two were diagnosed with repeat x-ray at follow up appointments. All five children had their toddler’s fracture correctly identified using POCUS at their initial presentation.
Although there are limited studies evaluating the use of POCUS in the diagnosis of toddler’s fractures, the small number of studies and case studies available are promising. As a point of care test in someone with appropriate training, this is a convenient potential diagnostic tool, particularly given the potential to reduce radiation exposure for children.
Toddler’s fractures do not need to be reduced and the management is largely supportive for 3-4 weeks. Standard treatment is a long leg back slab followed by a long leg walking cast.
A number of retrospective studies have looked at rates of immobilising toddler’s fractures when the diagnosis is either confirmed or presumed. They show that children with confirmed toddler’s fractures are more likely to be immobilised. But… a series of 75 children with radiographic evidence of toddler’s fractures, by Schuh et al., looked outcome following a variety of treatments (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 who were not immobilised walked much earlier than those who were immobilised in a controlled ankle movement (CAM) boot or splint. It was a mean of 4.1 days for the little ones not immobilised compared to 27.0 days for the smallies 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 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 that there were no complications with management in or out of a cast.
There is now a move towards recommending immobilisation in a CAM boot or 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 taken so as not to miss other diagnosis. If a child is not yet mobile, there must be a high suspicion for 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.
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