Outbreaks, Alerts and Hot Topics

Toddler’s Fracture

Author: Anik Patel, MD | Pediatric Emergency Medicine/Global Health Fellow

Mentor and Co-author: Lina Patel, MD | Director, Pediatric Emergency Medicine Fellowship Program | Associate Professor of Pediatrics, UMKC School of Medicine | Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Column Editor: Angela Myers, MD, MPH | Director, Division of Infectious Diseases | Professor of Pediatrics, UMKC School of Medicine | Medical Editor, The Link Newsletter

The term “toddler’s fracture” was first described by Dunbar et al. in 1964 as a spiral or oblique, non-displaced fracture of the distal one-third of the tibial shaft.¹ It typically occurs in children between the ages of 1 and 4 years.¹ This is an inherently stable injury secondary to the non-displaced fracture pattern and the thick overlying tissue called periosteum. Toddler’s fractures should be thought of as lower extremity “sprains” in young children.

Children with toddler’s fractures will usually present with a limp or refusal to bear weight on an extremity after tripping, stumbling or falling from a short height.² These are primarily low-energy rotational mechanisms that produce non-displaced oblique fractures; however, low-impact mechanisms can also cause stable non-displaced buckle fractures.

Examination of the child with a tibial fracture can be challenging due to the child’s distress toward medical providers as well as the subtlety of physical exam findings.² Allowing the patient to sit on their caregiver’s lap can facilitate the exam. It is often helpful to have parents assist with the examination by having them palpate along the extremities, from the hips down to the feet, and to allow them to perform range of motion to initially identify areas of concern. A focal area of tenderness over the anterior mid to distal tibia may be noted or pain with gentle twisting motion of the lower leg.³ When placed to stand or walk, patients often may refuse to bear weight or may walk with an antalgic gait.² 

The differential for a child with a limp is extensive, and includes several infectious or inflammatory etiologies, such as osteomyelitis, septic arthritis, skin and soft tissue infection, myositis, and transient synovitis; malignancy; rheumatologic conditions; and fractures secondary to accidental and non-accidental trauma.³ A high index of suspicion for non-accidental trauma should be maintained, especially if there is an inconsistent story or mechanism, if multiple fractures are present, or if the child is pre-ambulatory. In addition, if the pediatric patient is limping, non-musculoskeletal diagnoses should be considered, such as testicular torsion, appendicitis or incarcerated inguinal hernia.³

Initial radiographs should consist of antero-posterior, lateral and internal oblique views of the tibia/fibula when a toddler’s fracture is suspected.² Initial radiographs can often be negative; follow-up films one to two weeks after presentation can show signs of periosteal reaction and healing, confirming the presence of a fracture.³ In a 2019 study by Bauer et al., 39% of patients with a toddler’s fracture had negative initial radiographs and at follow-up, 93% showed evidence of fracture on repeat radiographs.⁴ 

In patients with suspected or confirmed toddler’s fractures, the preferred management is immobilization with a controlled ankle motion (CAM) or walking boot and referral to a pediatric orthopedist.² The prognosis is very good, with few complications if managed appropriately.² Skin breakdown due to splinting or casting is a potential complication, with as many as 17.3% of patients affected in one study.³ As such, CAM boots are recommended to provide support for the injury and avoid skin breakdown complications. In addition, studies have shown that CAM boots result in a faster return to weight-bearing compared to short leg casts.⁴ 

Patients should follow up with orthopedics one week after injury and four weeks after injury. Repeat X-rays will be obtained at the four-week visit. Most patients begin walking between two and four weeks and completely wean out of the CAM boot by four weeks; however, it is very common for patients to limp or walk “funny” for up to eight weeks after injury. Toddler's fractures do not involve the growth plate or have any known long-term effects on development or function.

Children’s Mercy has recently developed a care process model on the evaluation and management of toddler’s fractures.

References: 

1. Alqarni N, Goldman RD. Management of toddler’s fractures. Can Fam Physician. 2018;64(10):740-741.
2. Chapman J, Cohen J. Tibial and fibular shaft fractures in children. UpToDate. Accessed March 4, 2022.
3. Pattishall AE. An updated approach to toddler's fractures. J Urgent Care Med. September 2019.
4. 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.