The Case
A 21 month old male is refusing to walk after hurling himself down a playground slide. Mom tries to stand him up, and he crumples like a bean bag. He has some mild shin pain, but otherwise his exam is normal. You know the drill – and get an X-Ray.
The tibial fracture – represented by a tiny arrow shot from a tiny bow, held by an equally tiny archer
The Diagnosis
The toddler’s fracture is a nondisplaced spiral fracture of the mid to distal tibial. They occur in patients who have recently started walking – hence the name. The age range is generally 9 months to 3 years. The history is usually nondescript, and may include report of a child falling, twisting their limb awkwardly, or jumping off furniture. Children will limp refuse to bear weight. Point tenderness over the distal third of the tibia is easier to elicit when the child is calm.
Management
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. Pad the splint liberally and impress the importance of nonweightbearing with parents. Children should see Ortho within a week for casting.
Even if X-Rays are negative, but clinical suspicion is high (the child won’t ambulate or has focal tenderness over the distal third of the tibia) splint anyway and have them follow up with Ortho. Even if the X-Rays are still negative at follow up the will cast if the child refuses to bear weight. Fractures may not be radiographically apparent until healing begins. X-rays 10-14 days later may show periosteal reaction or sclerosis. Most toddler’s fractures heal without secondary sequelae, and surgery is almost never required.
Periosteal reaction of a healing fracture demonstrated by the arrow
The differential diagnosis includes other lower extremity fractures including those associated with non-accidental trauma, transient synovitis, septic hip, tumors and osteomyelitis.
HI Brad. Thanks for the post on toddler fractures. We have had some practice variation in our group and with our orthopedists in regards to the management of toddler fractures. I personally, after seeing some pressure sores from splints, have stopped splinting toddler fractures altogether. The available data I have seen has shown no increased risk of complication without splinting since the fracture is very stable. The child will likely just limp for a while. Some of our docs are doing short leg splints or casts in our ER, and some of our orthopedists have also recommended not splinting or casting.
A very good point Tal. I only splint if the child cannot and/or will not bear weight. When I splint I don’t use posterior lower leg splints as these seem to be related to pressure sores of the heel in particular (as you astutely noted). I will split those who don’t walk, but will use a stirrup and foot plate.