Figure 1. Anteroposterior radiograph of the left leg.
Figure 2. Lateral radiograph of the left leg.
A 2-year-old boy presents with his mother for evaluation of a 3-day history of lower extremity pain on the left side that causes him to limp. The child was playing on the playground at daycare when a staff member noticed his limp. Physical examination reveals mild swelling of the distal leg; otherwise, no deformity or bruising is present. The child refuses to ambulate on the left leg or let anyone examine him. Anteroposterior and lateral radiographs are obtained (Figures 1 and 2) and may suggest a toddler fracture.
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A toddler fracture is a low-impact fracture of the distal one-third of the tibia with an intact fibula; these fracture types usually occur in children aged ≤2.5 years.1 A toddler fracture can occur as the tibia is rotated and the foot is fixed to the ground, causing the classic spiral fracture pattern. The injury can occur while running or falling from a height. The injury frequently goes unnoticed by parents or caregivers, which may delay presentation to the clinic.
Common physical examination findings include swelling and refusal to bear weight on the affected extremity.1 The fracture is generally nondisplaced and may not be evident on initial radiographs.2 A toddler who presents to the office with a limp, pain along the affected tibia, and normal radiographs should be treated for a toddler fracture.
Treatment involves placing the child in a long-leg cast with the knee flexed at 30° to avoid weight-bearing.3 A healing callus may be evident along the periosteum as early as 2 to 3 weeks after the injury; this may be the only evidence that a fracture occurred. The differential diagnosis in a limping toddler may include other subtle fractures that are caused by minor trauma such as metatarsal buckle fractures, fractures of the midfoot, and fractures of the proximal tibia and distal tibia and fibula.1-3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
1. Edgington J, Swarup I, Vitale, M. Tibial shaft fractures — pediatric. OrthoBullets website. https://www.orthobullets.com/pediatrics/4026/tibial-shaft-fractures–pediatric. Updated January 7, 2020. Accessed June 17, 2020.
2. John SD, Moorthy CS, Swischuk LE. Expanding the concept of the toddler’s fracture. Radiographics. 1997;17(2):367-376.
3. Halsey MF, Finzel KC, Carrion WV, Haralabatos SS, Gruber MA, Meinhard BP. Toddler’s fracture: presumptive diagnosis and treatment. J Pediatr Orthop. 2001;21(2):152-156.