Ortho Dx: Pain and limping in a young child

Although initial radiographic examination is negative, a toddler's fracture is suspected in this patient. A toddler's fracture is a nondisplaced spiral fracture of the tibial shaft with an intact fibula. These fractures most commonly occur in children younger than 6...

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Although initial radiographic examination is negative, a toddler’s fracture is suspected in this patient. A toddler’s fracture is a nondisplaced spiral fracture of the tibial shaft with an intact fibula. These fractures most commonly occur in children younger than 6 years with an average age of 27 months.  The injury occurs as a low-energy rotational injury. Symptoms include inability or refusal to bear weight on the affected extremity, typically after sustaining an injury unwitnessed by the parent or caregiver.  Close examination starts with the uninvolved leg for comparison. The hip and ankle should be examined first to exclude other potential sources of referred pain. The location of point tenderness, swelling, and ecchymosis should be noted.

AP and lateral radiographs of the ipsilateral foot, ankle, tibia, and knee should be obtained; however, a fracture line is often not identified on initial radiographic examination.  Callus formation seen on radiographs 7 to 10 days after the injury may be the only evidence that the fracture occurred. Follow-up assessment approximately 2 weeks after the injury for repeat radiographs is recommended to confirm the diagnosis in equivocal cases.

Toddler’s fractures rarely require surgical intervention. Acceptable displacement includes 50% apposition, < 1 cm of shortening, and < 5 to 10 degrees of angulation in the sagittal and coronal planes. If a fracture line is seen or if fracture is suspected in this patient, a long-leg cast should be applied with the knee bent in slight flexion to provide rotational stability and prevent weight-bearing. The cast should remain on for 2 to 3 weeks, at which time repeat radiographic examination should be obtained following cast removal.  Depending on the results of radiographic and physical examinations, the patient may not require further immobilization.  If the child is still having pain at the fracture site and incomplete healing is evident on radiographs, then a short-leg cast for an additional two weeks is appropriate.