Is immobilisation required for toddler’s fracture of the tibia?
BMJ 2022; 379 doi: https://doi.org/10.1136/bmj-2022-071764 (Published 12 December 2022) Cite this as: BMJ 2022;379:e071764
- S Townley, ST5 paediatric trainee1,
- S Messahel, consultant in paediatric emergency medicine1,
- C Korownyk, professor of family medicine2,
- E Morely, parent coauthor1,
- D C Perry, NIHR research professor, professor of children’s orthopaedic surgery13
- 1Alder Hey Children’s Hospital, Liverpool L12 2AP, UK
- 2Department of Family Medicine, University of Alberta, Canada
- 3Faculty of Health and Life Sciences, University of Liverpool
- Correspondence to: S Townley sam.townley{at}alderhey.nhs.uk
What you need to know
There are no data or guidelines to suggest whether immobilisation is necessary for toddler’s fracture
We recommend that clinicians use their clinical judgment and engage families in shared decision making when deciding on immobilisation for toddler’s fracture
What is toddler’s fracture?
“Toddler’s fracture” describes a non-displaced, isolated, spiral or oblique fracture of the tibia. There are no high quality studies that identify the incidence of these fractures, but orthopaedic and emergency department experience indicate they are common in young children, typically occurring when they are ambulant (that is, toddlers) and between 9 months and 3 years old. They are usually the result of trivial injuries, such as a simple fall to the floor, though the mechanism is often not witnessed. They usually present with irritability and refusal to weight bear on the affected leg. Tenderness at the fracture site may be present, but it can be difficult to elicit.1 The diagnosis is made using radiographs (fig 1), though clinical acumen is important as initial radiographs can be normal in up to two thirds of cases.2 Indeed, both clinical and radiological signs are often unclear, making diagnosis challenging.3 Differentiating between accidental and non-accidental injuries is important in this age group, but we do not discuss this further in this paper.
(a) Plain anteroposterior (AP) radiograph of the tibia in a 2 year old showing a non-displaced spiral fracture through the tibia in the distal third of the diaphysis (arrow). There is no periosteal reaction. The findings are consistent with an acute toddler’s fracture. (b) Lateral radiograph of the same injury, though the fracture line is more subtle on this view (arrow)
How does toddler’s fracture differ from other common childhood fractures?
Toddler’s fracture typically results from a twisting force, whereby the bone fails in a spiral pattern, but an intact periosteum (the strong lining around the bone) is maintained, which provides inherent …