Toddler’s Fractures

A “toddler’s fracture” is a spiral or oblique fracture of the distal tibia in toddlers resulting from a low-energy trauma with a rotational/twisting component. These fractures are often seen in children who are learning to walk and who do not have a specific history of trauma. The child can sometimes present with a painful limp or refusal to bear weight on the affected limb. Management comprises analgesia and immobilizing the injured leg for several weeks.

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Overview

Definition

Non-displaced spiral fractures of the distal tibia are often called “toddler’s fractures,” as they are commonly seen in children who are just starting to walk.

Epidemiology

  • Most commonly seen in toddlers 9 months to 3 years of age, peak at 27 months
  • Can be seen in children as old as 11 years of age
  • Most commonly seen in tibia, but may affect all lower extremity bones
  • More common in boys

Etiology

  • Mechanism: 
    • Younger children: 
      • Low-energy twisting of foot with fixed knee
      • Often seen in children learning to walk
    • Older children: direct trauma
  • Less likely to be associated with child abuse than with metaphyseal corner or apophyseal ring fractures

Diagnosis and Management

Clinical presentation

Diagnosis of toddler’s fracture may be challenging due to lack of documented trauma and the inability of the child to localize injury:

  • May present with limp, antalgic gait, or refusal to bear weight
  • Delayed presentation is common.
  • Systemic symptoms (e.g., fever) should raise suspicion for infectious etiology (septic arthritis, osteomyelitis, myositis) or transient synovitis.

Signs:

  • Rarely, swelling and localized tenderness
  • Tenderness to palpation over distal tibia
  • Gentle twisting of ankle and knee in opposite directions elicits tibial pain.
  • Pain may be elicited by ankle dorsiflexion.
  • No obvious displacement or deformity
  • Patient often more comfortable positioned in caregiver’s lap during exam
Toddlers fractures examination

Exam finding for toddler’s fracture:
Gentle twisting of ankle and knee in opposite directions elicits tibial pain. During examination of the hip, rotational shear forces acting on the leg (arrows) can elicit pain in an injured tibia and this can be mistaken as a hip tenderness.

Image: “Examination of hip rotations” by American Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey. License: CC BY 2.0

Imaging

  • 2 views should be obtained (AP and lateral); additional oblique may be helpful.
  • Initial X-ray findings may be subtle: 
    • Fracture line often faint or absent
    • May be mistaken for blood vessel
  • Possible findings:
    • Spiral or oblique fracture mid-to-distal tibia
    • Periosteal reaction may be noted with delayed presentation.
  • If X-ray is negative, but high clinical suspicion, imaging may need to be repeated after 1–2 weeks to allow new periosteal bone formation.
  • In some cases, other imaging modalities (e.g., magnetic resonance imaging (MRI) and bone scintigraphy) may be needed to rule out other serious diagnoses (e.g., osteomyelitis).

Management

These fractures are usually non-displaced and are managed non-operatively. 

  • Supportive measures:
    • Analgesia
    • Make non-weight bearing or modified weight bearing
  • Casting:
    • Long-leg cast for 2–3 weeks
    • Follow with short-leg casting for 2–3 weeks

Clinical Relevance

Essential considerations in differential diagnosis of a child presenting with a limp:

  • Transient synovitis: acute, self-limiting inflammatory condition involving the hips. Most common cause of hip pain in children. Presents as a well-appearing child with limp or refusal to bear weight. Many patients report a history of recent flu-like illness. Physical examination of affected side shows mild restriction of range of motion with irritability of hip.
  • Acute osteomyelitis: acute bone infection often caused by hematogenous spread of bacterial pathogen. Most commonly identified causative organism in children is Staphylococcus aureus. Patients may present with fever, weight loss, erythema, swelling, tenderness to palpation, and antalgic gait. Supportive diagnostic testing includes lab tests for inflammation and infection and appropriate imaging studies. Definitive diagnosis often requires biopsy. Management includes parenteral antibiotics after cultures are obtained.
  • Septic arthritis: bacterial, viral, or fungal infection of joint synovial membrane and fluid. Most common causative organism is S. aureus. Majority of cases are monoarticular, with hip and knee joint most commonly involved. Children usually present with decreased range of motion or painful gait, fever, swelling, and irritability. Synovial fluid aspiration and examination is both diagnostic and curative. Antibiotic therapy is indicated and should be started as soon as cultures are obtained.
  • Osteosarcoma: most common primary malignant tumor of bone, most frequently found around the knee, causing localized pain, warmth, swelling, and limping. Has bimodal distribution affecting children (usually 10 + years old) and elderly patients.

Common fractures seen in pediatric age group:

  • Greenstick fracture: partial-thickness fracture that involves complete break of cortex and periosteum on only 1 side of bone. Termed “greenstick,” as it resembles a break in a live, “green” twig, where 1 side of the stick remains intact. High risk for refracture, and therefore should be completely immobilized. Rarely requires reduction, but should be managed cautiously to prevent malunion or angulation deformities; often should be referred for orthopedic follow-up.
  • Supracondylar fracture: complete fracture affecting the distal humerus after falling on outstretched hand (FOOSH). Commonly, fractures of the elbow in children. Requires immediate orthopedic consultation, as many cases are associated with neurovascular injury and require surgical intervention. 
  • Buckle or Torus fracture: fracture affecting growing metaphyseal bone secondary to compression load, where bone buckles or compresses. Generally considered a stable fracture. Treated by immobilization, and has a good prognosis.

References

  1. Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. J Am Acad Orthop Surg. 2005 Sep;13(5):345-52. doi: 10.5435/00124635-200509000-00008. PMID: 16148360.
  2. Patel NK, Horstman J, Kuester V, Sambandam S, Mounasamy V. Pediatric Tibial Shaft Fractures. Indian J Orthop. 2018;52(5):522-528. doi:10.4103/ortho.IJOrtho_486_17
  3. Setter KJ, Palomino KE. Pediatric tibia fractures: current concepts. Curr Opin Pediatr. 2006 Feb;18(1):30-5. doi: 10.1097/01.mop.0000192520.48411.fa. PMID: 16470159. Retrieved February 8, 2021, from https://online.boneandjoint.org.uk/doi/full/10.1302/2058-5241.3.170049

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