Case of toddler’s fracture in a 20-month-old
A 20-month-old boy, previously healthy, was brought to the emergency department due to pain and swelling in his left lower leg that had been present for over two hours. This discomfort arose immediately after he twisted his leg and fell following a push from his sibling. During the physical examination, the child was crying and unable to put weight on his left leg. Palpation revealed tenderness in the left lower leg, and there was pain when the ankle was passively bent upward. X-rays of the left lower leg revealed a slightly displaced spiral fracture of the tibial shaft (Panel A, anteroposterior view; Panel B, lateral view; “L” indicating left). Based on these findings, a diagnosis of a “toddler’s fracture” was established.
Unlike more severe fractures, toddler fractures are often minor and may not show up clearly on initial X-rays. However, they can become more visible on follow-up X-rays taken 1 to 2 weeks later. Treatment usually involves splinting, pain relief, and avoiding activities that put weight on the affected limb. By the 6-week follow-up, the fracture had healed, allowing the child to resume normal activities and weight-bearing.
Toddler’s fracture is a type of spiral tibia fracture seen in early walking children or preschoolers
Toddler fractures, a type of spiral tibia fracture seen in children from early walking to preschool age, typically result from low-energy twisting movements or falls. Limping in a child is a concern for both the child’s family and healthcare providers, who should rule out the possibility of a toddler’s fracture (TF). TFs typically affect young children who are walking, usually between 9 months and 3 years old.
These fractures often occur due to a rotational force applied to the tibia while the foot and ankle remain fixed, causing the upper leg to rotate inwardly. This type of injury commonly happens when a toddler trips while walking or running, or during a fall from a height. The term “toddler’s fracture” was introduced by Dunbar et al. in 1964 to describe a specific type of fracture—a non-displaced spiral or oblique fracture located in the distal third of the tibia, extending downward medially.
In the 1990s, the terminology was updated to childhood accidental spiral tibial fracture (CAST fracture), which provides a broader definition covering children up to the age of 8. The incidence of these fractures, previously known as TF, varies across different studies, ranging from 2.5 per 1000 children annually at the Royal Hospital for Sick Children in Edinburgh, Scotland, to 1 per 1000 children at Scotland’s Royal Aberdeen Children’s Hospital. Over time, various guidelines have been proposed for managing TF; however, a recent email survey involving all members of the Pediatric Emergency Research Canada network indicated significant variability in how TF is managed in practice.
Clinical assessment
The diagnosis of TF can be challenging during the initial assessment because there may be no clear history of injury, and examination findings such as crying may not pinpoint the exact location of pain. Tenenbein et al. from Manitoba noted that out of 37 cases of TF over a decade, only 35 had a definite history of injury, while another study of 39 cases found no distinct features among infants with a suspected TF, regardless of whether TF was confirmed on follow-up X-rays or not.
When TF was first identified by Dunbar et al., the inability to bear weight was considered a crucial indicator. However, this sign, while sensitive (82%) for TF, lacks specificity (30%). Local tenderness was nearly as sensitive (71%) but significantly more specific (67%). Gentle attempts to stress the tibia through axial torsion can sometimes provide diagnostic clues, although this manoeuvre may not be helpful if the child is in pain and resistant.
Radiographic evidence is crucial for confirming a fracture, but with TF, detecting a fracture line on initial X-rays can be challenging. A presumptive diagnosis is important for initiating prompt treatment, and a follow-up X-ray after 10 to 14 days can help confirm the diagnosis if a fracture line becomes visible. It’s recommended to use at least two views (anteroposterior and lateral) for imaging, and including an internal oblique view has shown to improve detection rates, catching 2 out of 7 (29%) missed TFs in one study. However, the discomfort associated with adjusting limb positioning for extra X-ray views should be taken into account.
In cases where plain radiographs are inconclusive, Lewis and Logan proposed using sonography in the emergency department for diagnosing TF, leveraging the fracture hematoma as a guide when traditional radiographs are insufficient.
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