Fracture healing stages

Toddler’s fractures

Figures 1a and 1b. X rays AP and lateral views show oblique fracture of the lower tibial shaft (Toddler’s fracture is difficult to see on lateral view) 

I share with you a 3 years old case of Toddler’s fracture. He complained of pain and inability to bear weight after twisting of his left leg. 

On examination, no swelling or deformity. He has full range of movement at the hip, knee, and ankle. His left leg was Warm and tender. X rays of the left leg show small fissure of lower tibia(Toddler’s fracture).

Review of literature 

Definition 

Toddler’s fractures are typically a spiral or oblique fracture through the distal third of the tibia. Radiological appearance are often subtle.

Incidence 

Toddler’s fractures occur in young children, mostly between nine months and three years of age.

Most common presentation 

Toddler’s fractures present with failure to bear weight on a leg after a minor trauma.

Mechanism of injury of Toddler’s fractures

Rotational force to the tibia usually occur with the foot and ankle fixed. There may be no history of trauma. However, onset of symptoms should be acute. 

Mechanism that is not irrelevant should raise suspicion for nonaccidental trauma.

Differential diagnosis 

-Septic arthritis and osteomyelitis: suspected if the child has fever and the leg is red, hot and swollen.

-Transient synovitis:

suspected if the child has a painful joint with a post infectious etiology.

-neoplasm

-nonaccidental trauma (child abuse)

-unclear cause of limp with abdominal pain may be outside the musculoskeletal system, such as inguinal hernia, appendicitis and testicular torsion. 

Physical Examination 

The child is usually distressed and has relatively subtle physical findings. The child may feel more comfortable and the  examination is easier in their caregiver’s lap. The examiner should begins the examination with the unaffected leg.

Examination of the affected extremity begins with the hip and knee followed by the foot and ankle, and finally the leg.

The lower extremities should be inspected for deformity, tenderness, redness, warmth (subperiosteal hematoma) and swelling.

 Neurovascular examination is done by monitoring the 5 P's: pain, pallor, pulse, paresthesia, and paralysis.

Patients with toddler’s fracture of tibia typically has tenderness over the lower third of the tibial shaft. The child often has pain with passive dorsiflexion of the foot. Range of movement of the knee and hip is typically normal.

Radiographic diagnosis 

Initial x rays are often negative, but after 1-2 weeks a periosteal reaction my appear as a sign of fracture healing. About 39% of patients had negative x-rays at presentation, with 93% of these showing evidence of fracture after 1-2 weeks. 

Toddler’s fractures are often seen on the anteroposterior view, hardly seen on the lateral and better visualized on the internal oblique view. 

Ultrasound can detect the presence of a fracture hematoma and thus may help diagnose this injury while minimizing radiation exposure.

Spiral fractures of the midshaft tibia are usually suspicious for child abuse.

Treatment 

Treatment of Toddler’s fractures  are conservative with immobilization. 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 physician. 

Other methods of immobilization are: above knee casting, below knee casting, and below knee posterior splinting.

Confirmed fractures are conservatively treated mostly with above knee circumferential casting, while short leg back   was most common in suspected cases.

Follow-up

For most children, orthopedic follow-up may not be needed. X rays may be needed after 2 weeks. 

Prognosis

Prognosis of toddler’s fractures is excellent, regardless of the management method. Recent studies have not reported any complications.

Reference 

1. Jennissen CA, Koos M, Denning G. Playground slide-related injuries in preschool children: increased risk of lower extremity injuries when riding on laps. Inj Epidemiol. 2018. 5(Suppl 1):13.
2. Mellick LB, Reesor K. Spiral tibial fractures of children: a commonly accidental spiral long bone fracture. Am J Emerg Med. 1990;8(3):234-237.
3. Bauer JM, Lovejoy SA. Toddler’s Fractures: time to weight-bear with regard to immobilization type and radiographic monitoring. J Pediatr Orthop. 2019. 39(6):314-317.
4. Halsey MF, Finzel KC, Carrion WV, et al. Toddler’s fracture: presumptive diagnosis and treatment. J Pediatr Orthop. 2001;21(2):152-156.
5. Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins Health; 2010.