Toddler Fracture

Toddler fracture is a spiral or oblique non-displaced fracture of the distal tibial shaft in a child aged 9 months to 3 years, typically caused by a minor twisting injury.

• It occurs when the child is learning to walk, often from a fall, a twist while the foot is planted, or with no clear trauma.
• The periosteum is thick in young children and stays intact, so there is little displacement and the fracture can be invisible on early X-ray.
• Non-accidental injury should be considered, particularly in non-ambulant infants and in the presence of other injuries or an inconsistent history.
• Healing is rapid, with an excellent outcome.

The child refuses to walk or bear weight.

• Sudden onset of limping, refusal to bear weight or crawling on the affected leg, sometimes following a minor fall or twist.
• Pain on palpation of the tibia, mild swelling and warmth.
• Reluctance to move the leg and crying with handling.
• No wound and no obvious deformity.
• Fever is usually absent. Fever suggests infection.
• Differential diagnosis: osteomyelitis, septic arthritis of hip or knee, transient synovitis, soft tissue injury, foreign body in the foot, discitis, juvenile idiopathic arthritis, leukaemia and non-accidental injury.
• Complications: delayed diagnosis, malunion (rare), leg length discrepancy (rare), and missed child abuse.

Diagnosis is clinical and radiological.

• Examine the whole leg, hip, knee, foot and spine for point tenderness, swelling and warmth. Check the foot for foreign bodies and examine for bruises elsewhere.
• X-ray of the tibia and fibula (anteroposterior and lateral, with an oblique view): a thin spiral line in the distal tibial shaft, often subtle or absent in the first 1 to 2 weeks.
• If X-ray is normal and suspicion remains, immobilise and repeat X-ray in 7 to 10 days (periosteal reaction appears). Ultrasound or bone scan can identify occult injury.
• Full blood count, C-reactive protein and erythrocyte sedimentation rate if fever or infection suspected.
• Skeletal survey and safeguarding review if non-accidental injury is suspected.

Immobilisation for 3 to 4 weeks.

• Supportive: analgesia, elevation and reassurance. The child may bear weight as pain permits.
• Pharmacological: paracetamol 15 mg/kg every 6 hours, ibuprofen 5 to 10 mg/kg every 8 hours.
• Procedures: below-knee plaster cast or walking boot for 3 to 4 weeks (full weight bearing allowed as tolerated). No reduction needed.
• Special groups: infants who are not yet walking with a tibial fracture need a skeletal survey and child protection assessment.
• Red flags: fever, inconsistent history, other injuries, bruising of different ages, non-ambulant infant, delayed presentation, and severe pain unrelieved by immobilisation.
• Follow-up: review at 2 weeks and at cast removal around 3 to 4 weeks. Repeat X-ray if the diagnosis was presumed. Expect full recovery.