Toddler's fracture

Background

• Also known as Childhood Accidental Spiral Tibial (CAST) fracture
• Nondisplaced (or minimally displaced) spiral fracture of the tibia
• Typically encountered in ambulating toddlers (9 months - 3 years) due to low energy trauma with rotational component (i.e. twisting body while one leg is planted).
• NOT generally associated with non-accidental trauma.

Clinical Features

• History of an otherwise healthy child, who was ambulating, falls and is then non-ambulatory or has painful ambulation.
• Usually pain with palpation and rotation of distal tibia
• Swelling may be minimal or absent

Differential Diagnosis

Pediatric Tibial Fractures

• Toddler's fracture
• Tibial spine fracture
• Tibial tuberosity fracture

Evaluation

A toddler's fracture

• X-ray of affected limb
  • May only present as faint oblique line on AP view
  • May need oblique view if strong suspicion but AP/lat are negative

Management

General Fracture Management

• Acute pain management
• Open fractures require immediate IV antibiotics and urgent surgical washout
• Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention
• Consider risk for compartment syndrome

Specific Management

• Definite fracture
  • Immobilize in long leg splint (knee flexed to provide rotational control and prevent weight bearing)
  • Ortho follow up next day for definitive casting. Usually takes 3-4 weeks for healing without further intervention.
  • Serial radiographs to monitor for developing deformity (ie leg length discrepancy or varus/valgus angular deformity).
• Negative x-ray with high suspicion for occult fracture
  • Immobilize and follow up with ortho for bone scan or repeat x-ray in 1 week

Disposition

• Discharge with ortho follow-up

See Also

• Tibia fracture (peds)