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