Society for Pediatric Urgent Care

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Society for Pediatric Urgent Care

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TODDLERS FRACTURE

EPIDEMIOLOGY OF TIBIAL SHAFT FRACTURES

  • 15 percent of all pediatric fractures are in the tibial shaft
  • 39% tibial fractures are in diaphysis
  • 30% associated with fibula fracture

TODDLERS FRACTURES

  • Non displaced spiral or oblique fracture of tibial shaft only (fibula remains intact)
  • Also known as CAST fracture (childhood accidental spiral tibial fracture)
  • Usually low energy trauma with rotational component (ex: twisting of leg when sliding down slide and foot gets caught on side of slide)

AGE CONSIDERATIONS

  • Walking toddlers: 9m to 36m

DIFFERENTIAL DIAGNOSIS

  • NAT
  • Infection (if pt comes in 7-10 days later and has concerning findings on XR discussed in diagnostic findings)
  • Bowing fracture
  • Buckle fracture
  • Pathologic fracture (due to neuromuscular disease, osteogenesis imperfecta, bony lesions)
  • Transverse fracture (usually related to trauma)

EVALUATION

HISTORY

  • Location of pain (if able to answer), mechanism (often has a rotation component), if there is a limp

  • Pain
  • Bruising
  • Limp/refusal to bear weight

PHYSICAL EXAM

  • Warmth, swelling over fracture site
  • Tenderness over site
  • Pain on ankle dorsiflexion
  • If none of these are found (often with the classic toddlers fracture – place hand at knee and ankle and twist the leg and this should elicit pain

DIAGNOSTIC FINDINGS

  • XR AP and lateral of leg: nondisplaced spiral tibial shaft fracture (usually distal half)
  • If find healing and periosteal reaction could be due to previous fx in past 7-10 days – MRI or CT warranted to assess for infection or other etiology

CONCERNING FINDINGS

  • Pain out of proportion to exam, pallor, pulseless (think of compartment syndrome
  • Fracture at proximal half of tibia (concern for NAT)

TODDLERS FRACTURE

TREATMENT

Non Operative

  • Closed reduction and long leg casting
    Is used for most toddlers fractures

Operative – Indications (usually with other tibial shaft fractures, rarely with toddlers)

  • Unacceptable reduction
  • Marked soft tissue injury
  • Open fractures
  • Unstable fractures
  • Compartment syndrome
  • Neurovascular injury
  • Multiple long bone fractures

FOLLOW UP

After Non-operative option

  • Follow up XR in 2 weeks to evaluate for callus in cases where diagnosis was unclear
  • Serial radiographs to monitor for developing deformity

After surgery

  • Will be case dependent

Prognosis

  • 3-4 weeks for toddlers fractures to heal

COMPLICATIONS

  • Compartment syndrome
  • Leg length discrepancy
  • Angular deformity (Varus or valgus)
  • Associated physeal injury

Anticipatory Guidance

  • Come back for persistent or progressive pain while in cast
  • Come back for numbness/tingling (although hard to elicit for the younger kids)
  • Come back for swelling or discoloration of toes outside cast

REFERENCES

  1. Orthobullets
  2. Uptodate