Toddler's Fracture
Toddler’s fractures are generally straightforward and are not traditionally associated with abuse - Derek Lubetkin
image by: Natasha Smith Cutlip
HWN Suggests
A Toddler’s Tibia: Common Yet Obscure
In a March 1964 address to the Canadian Association of Radiologists, Dr. J.S. Dunbar, MD stated that when a child "fails to bear weight on the leg," he most often has an obscure fracture of the tibia called the "toddler's fracture".
Typical presentation
Toddler’s fractures usually occur after a child begins to ambulate on two legs, thus placing weight on the tibia. The incidence is greatest between the ages of 9 months and 3 years. The child typically presents with refusal to bear weight and increased irritability. There may or may not be a report of antecedent trauma or injury, and often the injury may be seemingly insignificant.
Radiology
A…
Resources
An Updated Approach to Toddler Fractures
Toddler’s fractures are a common cause of limp and failure to bear weight in children under 4 years of age. Recent research shows wide variation in management of these stable fractures, favoring a less conservative approach.
SplintER Series: A Toddler’s Missed Step
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.
Toddler's Fracture - CAM Walker Boot, Cast, or Nothing?
Although this study cannot provide conclusive management recommendations, when all these articles are considered together, I feel affirmed in my current practice, which is to place confirmed or suspected TFs in a CAM walker boot.
Toddling along, until they’re not…
X-Rays naturally make the diagnosis, with AP and lateral tib/fib the films du jour. You may only see a faint hairline fracture or a more obvious oblique or spiral fracture. Splinting is with a long leg posterior with the foot in neutral position, and the knee slightly flexed. Children will find a way to get around in a splint (crawing, scoot or walk) leading to an increased risk of pressure sores.
Activities with an Active Toddler with a Toddler’s Fracture
If you ever experience having a child with a toddler’s fracture, the most important thing is not to lose hope. Although the situation is tough, it’s really not the end of the world. Kids are resilient.
It’s tough being a kid: Toddler’s fracture
Fractures in nonambulatory children or children in which a given history is not compatible with either physical examination or imaging findings should prompt concerns for nonaccidental trauma. In these children, appropriate imaging, including a skeletal survey and, if indicated, neuroimaging, should be obtained, as recommended by the American Academy of Pediatrics and other organizations.
Lightning Learning: Toddler's Fracture
Axial load: place hand at knee and ankle, then gently twist the leg – this would elicit pain.
Management of toddler’s fractures
A controlled ankle motion boot or a short leg back slab are preferred because they are associated with fewer complications and can be removed by the family or the family physician.
Should Toddler's Fracture Be Renamed?
There have been several series of isolated spiral tibial fractures in children, all with similar findings. Most importantly, there is agreement that the mechanism is almost always accidental; only a careful history will reveal cases in which abuse should be suspected. The authors propose a new name, Childhood Accidental Spiral Tibial (CAST) fracture, which is a more accurate description of this injury.
What Is Toddler's Fracture and How Can You Treat It?
Toddler’s fracture can be quite common in children who are learning to walk. Although it isn’t very serious, it can have both physical and mental consequences for children.
What To Do When Your Toddler Has A Fracture
The time required for a fracture to heal depends on the age of the child, location and nature of the injury. Legs are casted longer than arms because they need to be strong enough to stand on.
A Toddler’s Tibia: Common Yet Obscure
Plain films may be negative on initial evaluation, thus if injury and presentation are consistent with toddler’s fracture, a CAM boot/short leg splint or cast should be considered until follow-up films can be obtained seven days later.
Bone Talks
The injured leg is rarely significantly swollen but its classically tender and especially sensitive to any rotation, like turning to foot outward, because this recreates the same rotational force that caused the initial crack.
Don't Forget the Bubbles
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.
Pediatric EM Morsels
The limping toddler offers the opportunity for us to contemplate a wide differential that includes some significant pathologic processes. Does this child have avascular necrosis of the femoral head? Is there slipped capital femoral epiphysis? Is there evidence of rheumatologic disease? Also known as “Childhood Accidental Spiral Tibial (CAST) fracture.”
WikEM
Typically encountered in ambulating toddlers (9 months - 3 years) due to low energy trauma with rotational component (i.e. twisting body while one leg is planted). NOT generally associated with non-accidental trauma.
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