High-yield overview

Toddler's Fracture | Cozen's Phenomenon | Tibial Spine

15%Of pediatric fractures

9m-3yToddler's fracture age

8-14yTibial spine age

12-18mCozen's valgus remodeling

KEY INJURY PATTERNS

Toddler's Fracture

PatternSpiral tibia in 1-3 year old, often occult

TreatmentCast 3-4 weeks

Prox Metaphyseal

PatternMay develop Cozen's valgus deformity

TreatmentCast, monitor for valgus

Tibial Spine

PatternPediatric ACL equivalent

TreatmentType I-II cast, III surgical

Shaft Fractures

PatternHigh remodeling potential

TreatmentAge-based: cast vs flexible nails

Critical Must-Knows

Toddler's fracture: spiral tibia in 9 months to 3 years, limping child, X-ray often normal initially
Cozen's phenomenon: progressive valgus after proximal tibial metaphyseal fracture, self-corrects
Tibial spine fracture = pediatric ACL injury - treat based on displacement
Floating knee in children: ipsilateral femur and tibia fractures - high energy
Intact fibula may cause valgus deformity in tibial shaft fractures

Clinical Pearls

"
Negative X-ray does not rule out toddler's fracture - treat clinically if suspected
"
Cozen's valgus peaks at 12-18 months then spontaneously corrects - observe
"
Tibial spine Type III = surgical (ORIF or arthroscopic reduction)
"
Age over 10 years: consider flexible IM nails for tibial shaft fractures

Critical Exam Concepts

Toddler's Fracture

Non-displaced spiral tibia in walking child 9 months to 3 years. X-ray often negative initially. Clinical diagnosis - limp, refuse to bear weight. Cast 3-4 weeks even if X-ray negative.

Cozen's Phenomenon

Progressive valgus after healed proximal tibial metaphyseal fracture. Develops 6-12 months post-injury, peaks at 18 months. Self-corrects by skeletal maturity. DO NOT overcorrect initially.

Tibial Spine Fractures

Pediatric ACL equivalent. Meyers-McKeever classification. Type I/II = non-operative (extension cast). Type III/IV = surgical reduction and fixation.

Floating Knee

Ipsilateral femur and tibia fractures = high energy. Screen for other injuries. May need surgical stabilization of both levels. Higher complication rate.

Quick Decision Guide by Fracture Type

Fracture	Age	Key Feature	Treatment
Toddler's fracture	9 months - 3 years	Spiral tibia, often occult	Cast 3-4 weeks
Proximal metaphyseal	3-10 years	Risk of Cozen's valgus	Cast, observe for valgus
Tibial spine	8-14 years	ACL equivalent	Type III = surgical
Shaft fracture	All ages	High remodeling	Cast or flexible nails
Floating knee	Any age	High energy	Surgical stabilization

Mnemonic

SPIRALToddler's Fracture Features

S	Spiral fracture pattern Classic oblique/spiral non-displaced
P	Pain with weight bearing Refuses to walk, limps
I	Imaging often negative X-ray may be normal initially
R	Rotational mechanism Twisting injury from fall
A	Age 9 months to 3 years Typically walking age
L	Low energy injury Minor fall, no significant trauma

S	Spiral fracture pattern Classic oblique/spiral non-displaced	I	Imaging often negative X-ray may be normal initially	A	Age 9 months to 3 years Typically walking age
P	Pain with weight bearing Refuses to walk, limps	R	Rotational mechanism Twisting injury from fall	L	Low energy injury Minor fall, no significant trauma

Hook:SPIRAL describes both the fracture pattern and key features!

Mnemonic

VALCozen's Phenomenon

V	Valgus deformity develops Progressive valgus 6-18 months post-injury
A	After proximal tibial metaphyseal fracture Classic location
L	Leaves spontaneously Self-corrects by skeletal maturity

V	Valgus deformity develops Progressive valgus 6-18 months post-injury
A	After proximal tibial metaphyseal fracture Classic location
L	Leaves spontaneously Self-corrects by skeletal maturity

Hook:VAL-gus develops then VAL-ishes (vanishes)!

Mnemonic

1234Meyers-McKeever Tibial Spine

1	Type I - Minimally displaced Non-operative, extension cast
2	Type II - Anterior hinge Usually non-operative, may need reduction
3	Type III - Completely displaced Surgical fixation required
4	Type IV - Comminuted Surgical fixation required

1	Type I - Minimally displaced Non-operative, extension cast	3	Type III - Completely displaced Surgical fixation required
2	Type II - Anterior hinge Usually non-operative, may need reduction	4	Type IV - Comminuted Surgical fixation required

Hook:Type 3+ = Surgery (the 3 looks like a backwards S for Surgical)

Overview and Epidemiology

Age Distribution

Different tibial fracture patterns occur at different ages. Toddler's fracture (9 months to 3 years), proximal metaphyseal Cozen's type (3-10 years), tibial spine (8-14 years), shaft fractures (all ages).

Epidemiology

Second most common pediatric long bone fracture
15% of all pediatric fractures
Peak incidence: toddlers and adolescents
Boys more than girls (2:1)
Left and right equal

Mechanisms

Toddler's: low energy twist/fall
Proximal metaphyseal: direct impact
Tibial spine: hyperextension (bicycle)
Shaft: direct blow or torsion
Floating knee: high energy (MVA)

Anatomy and Biomechanics

Pediatric Tibial Anatomy

The proximal tibial physis grows faster than the distal (57% vs 43% of tibial growth). Injuries to the proximal physis have greater potential for growth disturbance.

Tibial Growth Plate Anatomy

Proximal tibial physis: Contributes 57% of tibial length. Located 1-2 cm distal to joint line. Protected by tibial tubercle apophysis.

Distal tibial physis: Contributes 43% of tibial length. Asymmetric closure (central, then medial, then lateral).

Tibial tubercle apophysis: Secondary ossification center. Vulnerable during adolescence (Osgood-Schlatter).

Classification Systems

Toddler's Fracture (CAST)

Childhood Accidental Spiral Tibial fracture

Characteristics: Age 9 months to 3 years (walking age). Non-displaced spiral or oblique fracture. Distal tibial shaft most common. Often not visible on initial X-ray. Low energy mechanism (twist, fall).

Clinical Assessment

Toddler's Fracture

Refuses to bear weight
Limping or not walking
Point tenderness over tibia
Often no swelling initially
May have normal X-rays
History of minor fall/twist

Tibial Spine

Acute knee pain after hyperextension
Knee effusion (hemarthrosis)
Unable to extend knee fully
Positive Lachman (if tested)
Often bicycle handlebar injury

Floating Knee Assessment

High energy injury. Assess for associated injuries: ipsilateral hip, knee, ankle. Neurovascular exam essential. Screen for head, chest, abdominal trauma. Higher risk of compartment syndrome.

Compartment Syndrome Risk

Be vigilant for compartment syndrome especially in floating knee, both bone fractures, and high energy mechanisms. Pain out of proportion, pain with passive stretch, tense compartments.

Investigations

X-ray Protocol

Views: AP and lateral tibia/fibula. Include knee and ankle joints.

Toddler's fracture: May be negative initially. Look for subtle periosteal reaction at 10-14 days. Bone scan or MRI if clinical suspicion high.

Tibial spine: AP and lateral knee. CT if surgical planning needed.

Management

Age-Based Treatment Principles

Under 6 years: Cast treatment for most fractures. High remodeling potential. 6-10 years: Cast for stable, operative for unstable or acceptable alignment not achieved. Over 10 years: Consider flexible IM nails for shaft fractures. Lower remodeling potential.

Toddler's Fracture Management

Treatment: Long leg cast or walking boot for 3-4 weeks.

Key points:

Treat clinically even if X-ray negative
No reduction needed (non-displaced)
Rapid healing in this age group
Follow-up X-ray at 2 weeks shows callus

Prognosis: Excellent. Heals rapidly with no long-term sequelae.

Acceptable Deformity in Pediatric Tibia

Angulation: Up to 10 degrees in sagittal plane, 5 degrees in coronal plane. Shortening: Up to 1-1.5 cm (will remodel with growth). Rotation: Minimal accepted (does not remodel). Younger children tolerate more deformity due to greater remodeling potential.

Surgical Technique Considerations

Flexible IM Nailing (TENS/ESIN)

Indications: Age over 6-10 years, unstable shaft fractures, polytrauma.

Entry points: Medial and lateral distal metaphysis (avoid physis).

Nail size: 40% of medullary canal at isthmus.

Key points: Pre-contour nails for apex anterior angulation. Avoid proximal entry (tibial tubercle physis damage).

Complications

Complications by Fracture Type

Complication	Fracture Type	Management
Cozen's valgus	Proximal metaphyseal	Observe - self-corrects by maturity
Malunion	Shaft fractures	Remodeling or corrective osteotomy if needed
ACL laxity	Tibial spine	Proper reduction and fixation, ACL rehab
Compartment syndrome	Floating knee, high energy	Urgent fasciotomy
Growth arrest	Physeal injuries	Bar resection or corrective procedures
Nonunion	Rare in children	Operative intervention if occurs

Cozen's Phenomenon

Progressive valgus deformity after proximal tibial metaphyseal fracture. Mechanism unclear (asymmetric growth stimulation, tethering by fibula). Develops 6-18 months post-fracture. Spontaneous correction expected by skeletal maturity. Osteotomy rarely indicated before maturity.

Postoperative Care

Post-Treatment Protocol

Week 0-2Immediate Post-Injury

Cast immobilization. Non-weight bearing. Monitor for compartment syndrome in high-energy injuries.

Week 2-6Healing Phase

X-ray at 2-3 weeks to confirm alignment. Toddler's fracture usually healed. Weight bearing as tolerated in cast.

Week 6-12Cast Removal

Remove cast when clinically and radiographically healed. Begin weight bearing. Tibial spine: begin ROM.

Months 6-24Monitoring

Follow proximal metaphyseal fractures for Cozen's valgus. Document and reassure. Tibial spine: assess for ACL laxity.

Outcomes and Prognosis

Prognosis by Fracture Type

Toddler's fracture: Excellent prognosis. Complete healing in 3-4 weeks. No long-term sequelae.

Proximal metaphyseal: Good prognosis despite Cozen's phenomenon. Most remodel by skeletal maturity.

Tibial spine: Good outcomes with proper treatment. Residual ACL laxity possible but usually not symptomatic.

Shaft fractures: Excellent prognosis. High union rates. Good remodeling potential in younger children.

Special Considerations

Floating Knee (Pediatric)

Definition: Ipsilateral femur and tibia fractures.

Mechanism: High energy trauma (MVA, fall from height).

Associated injuries: Knee ligament injuries (40-80%), vascular injuries, other trauma.

Management: Usually requires surgical stabilization of both levels. Femur typically flexible nails. Tibia cast or nails depending on pattern.

Complications: Highest risk of compartment syndrome. LLD possible.

Differential Diagnosis

The limping or non-weight-bearing child

A toddler refusing to weight-bear with a normal radiograph has a broad differential. The job is to separate a benign occult fracture from infection, malignancy and non-accidental injury before reassuring the family.

Differentiating Pediatric Tibial Fracture Patterns and Mimics

Condition	Typical age	Key discriminator	Pitfall to avoid
Toddler's fracture	9 months - 3 years	Point tibial tenderness, low-energy twist, periosteal reaction at 10-14 days	Calling it 'normal' on day 1 film
Osteomyelitis / septic arthritis	Any	Fever, raised CRP/ESR, warmth, refusal to move joint	Casting an infected limb
Non-accidental injury	Pre-ambulatory or inconsistent history	Mechanism-injury mismatch, other injuries on survey	Failing to safeguard a young child
Transient synovitis	3-8 years	Hip-referred pain, recent viral illness, settles quickly	Missing a tibial source of pain
Bone tumour / cyst (pathological)	Any	Pain before injury, lytic lesion, trivial trauma	Treating fracture without imaging the lesion
Cozen's valgus vs true malunion	3-10 years	Cozen's appears 8-19 months after a healed metaphyseal fracture	Blaming initial treatment for late valgus

Controversies and Areas of Uncertainty

Cozen's: predict or just watch?

Age, sex and initial angulation do not reliably predict who develops late valgus, and the deformity usually self-corrects. Routine prophylactic intervention is not justified; the debate is how long to observe before offering guided growth.

Tibial spine: suture vs screw vs anchor

Comparative data favour suture-based fixation for function and lower implant-removal rates, but no high-quality randomised trial defines the optimal construct. Open versus arthroscopic reduction also remains debated.

Operative threshold in adolescents

The angulation/shortening a growing tibia will remodel is age-dependent and imprecise. Heavier, older adolescents behave more like adults, narrowing the case for purely closed treatment.

Imaging the occult toddler's fracture

MRI, bone scan and ultrasound can confirm occult fractures, but most authorities treat clinically without advanced imaging. The controversy is cost and radiation versus diagnostic certainty.

Evidence Base and Key Studies

How to read these cards

Each card below is anchored to a verified PubMed record (PMID and DOI shown). Use the level of evidence and sample size to judge how heavily to lean on a given statement in a viva.

Cozen's Phenomenon: Natural History and Resolution

Papamerkouriou YM, Tsoumpos P, Tagaris G, Christodoulou G • J Child Orthop (2020)

Key Findings:

Retrospective series of 33 children (6 months to 14 years), mean follow-up 8.8 years
15 of 33 developed late valgus between 8 and 19 months (mean onset 12.5 months)
24 of 33 developed tibial elongation; neither finding correlated with age at injury
Maximum valgus subsequently corrected to near the initial post-treatment angle by final follow-up

Clinical Implication: Warn families that late valgus is common after proximal tibial metaphyseal fractures and reassure them that spontaneous correction is the expected course.

Limitation: Single-centre retrospective study with modest numbers and no control group.

Verify on PubMed (PMID 32582389)

Guided Growth for Persistent Cozen's Deformity

Morin M, Klatt J, Stevens PM • Strategies Trauma Limb Reconstr (2018)

Key Findings:

Largest reported series (19 patients, 24 Cozen's phenomena) treated with medial proximal tibial guided growth
Corrective osteotomy abandoned because of frequent recurrent valgus
Mechanical axis and medial proximal tibial angle corrected in all but one patient
Five recurrences after implant removal; managed by repeat or retained metaphyseal screw

Clinical Implication: Reserve intervention for deformity that fails to resolve; guided growth (hemiepiphysiodesis) is preferred over osteotomy when surgery is genuinely needed.

Limitation: Retrospective series, no control cohort, variable follow-up.

Verify on PubMed (PMID 29549568)

Tibial Eminence Fractures: Surgical Outcomes Systematic Review

Limone B, Zambianchi F, Cacciola G, Seracchioli S, Catani F, Tarallo L • Children (Basel) (2023)

Key Findings:

Systematic review of 12 studies of operatively treated Meyers-McKeever type II-IV fractures
Open reduction showed higher Tegner/Lysholm scores and less arthrofibrosis than arthroscopic fixation
Arthroscopic suture fixation outperformed arthroscopic screw fixation on functional scores
Screw fixation carried the highest rate of implant removal

Clinical Implication: Suture-based fixation is a sound default for displaced tibial spine fractures; counsel that implant removal is more likely with screws.

Limitation: Heterogeneous pooled retrospective data; no randomised comparison.

Verify on PubMed (PMID 37628378)

Arthroscopic Fixation Techniques for Pediatric Tibial Eminence Fractures

Li C, Huang X, Yang Q, Luo Y, Li J, Ye S, Lu W, Zhang X, You T • Front Pediatr (2024)

Key Findings:

Narrative review confirming arthroscopic reduction as the contemporary standard for surgical TEFs
Anchor, suture and screw constructs gave broadly comparable clinical and radiographic results
Suture/anchor techniques minimise physeal damage and are favoured in skeletally immature knees
Higher-quality comparative studies are still needed to define the optimal construct

Clinical Implication: Choose the fixation construct that achieves stable reduction while sparing the physis; technique choice is driven by surgeon experience and fragment quality.

Limitation: Narrative review without pooled statistics or quality grading.

Verify on PubMed (PMID 38596248)

Titanium Elastic Nails for Pediatric Tibial Shaft Fractures

Sankar WN, Jones KJ, Horn BD, Wells L • J Child Orthop (2007)

Key Findings:

19 consecutive children (mean age 12.2 years) with unstable tibial shaft fractures treated with TENs
All united at a mean of 11 weeks; final mean angulation 2 degrees sagittal, 3 degrees coronal
No leg-length discrepancy or physeal arrest; entry-site irritation in 26 percent
12 excellent, 6 satisfactory and 1 poor result by Flynn criteria

Clinical Implication: Elastic stable intramedullary nailing is safe and effective for unstable shaft fractures in older children, with rapid union and few major complications.

Limitation: Small single-centre retrospective cohort.

Verify on PubMed (PMID 19308521)

Adolescent Tibial Shaft Fractures: Treatment Outcomes and Risk Factors

Thabet AM, Craft M, Pisquiy J, Jeon S, Abdelgawad A, Azzam W • Injury (2021)

Key Findings:

52 patients aged 10-18 years treated by ESIN, interlocking nail, plate, external fixator or cast
No significant difference in union rate between fixation methods
Open fractures had longer time to union and a 5.5-fold higher complication risk
Heavier body weight correlated with lower radiographic union scores at 12 weeks

Clinical Implication: No single method fits all adolescents; soft-tissue status and body weight matter more than the specific implant chosen.

Limitation: Single-centre retrospective comparison with limited numbers per subgroup.

Verify on PubMed (PMID 34862039)

Occult Toddler's-Type Tibial Fractures

Swischuk LE, John SD, Tschoepe EJ • Pediatr Radiol (1999)

Key Findings:

Described subtle, easily missed occult tibial fractures in infants and young children
Radiographic findings parallel the classic spiral toddler's fracture of Dunbar
Knowledge of mechanism plus focused exam allows confident diagnosis
Reinforces that initial radiographs are frequently unremarkable

Clinical Implication: A normal initial radiograph does not exclude a toddler's-type fracture; correlate with mechanism and point tenderness.

Limitation: Retrospective radiographic case series.

Verify on PubMed (PMID 9880607)

Foundational Classification & Description (Historical)

Guideline

Meyers MH & McKeever FM; Cozen L; Dunbar JS et al. • J Bone Joint Surg Am / J Can Assoc Radiol (1953-1964)

Key Findings:

Meyers-McKeever (1959/1970) defined the tibial spine fracture classification still used today
Cozen (1953) first described post-traumatic proximal tibial valgus
Dunbar et al. (1964) coined the 'toddler's fracture' as a childhood accidental spiral tibial fracture
These remain the eponymous source descriptions for the entities on this page

Clinical Implication: Quote the eponyms accurately in vivas; the modern evidence above refines, but does not replace, these original descriptions.

Limitation: Historical descriptive works predating modern levels-of-evidence grading.

Exam Viva Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

Scenario 1: Limping Toddler

CLINICAL PROMPT

"A 2-year-old child is brought to ED by his mother. He has been refusing to bear weight on his left leg since yesterday after a fall from a low chair. On examination, there is no obvious swelling but tenderness over the distal tibia. X-rays appear normal. How would you manage this?"

PRACTICAL APPROACH

This is a classic presentation of a toddler's fracture. The history of a low-energy fall, age around 2 years, refusal to weight bear, and point tenderness over the tibia despite normal X-rays is highly suggestive. Toddler's fractures are non-displaced spiral or oblique fractures of the tibial shaft that are often not visible on initial radiographs due to their subtle nature. My management would be to treat this child clinically as a presumed toddler's fracture. I would apply a long leg cast or below-knee walking boot for 3-4 weeks. I would counsel the parents that while the X-ray appears normal, the clinical picture is consistent with this fracture. A follow-up X-ray at 2 weeks would typically show periosteal new bone formation confirming the diagnosis. The prognosis is excellent with complete healing expected and no long-term sequelae.

KEY CLINICAL POINTS

Toddler's fracture: age 9 months to 3 years

X-ray often negative initially

Clinical diagnosis - treat if suspected

Cast or boot for 3-4 weeks

Excellent prognosis

COMMON PITFALLS

Dismissing because X-ray is normal

Not examining for other causes of limp

Ordering unnecessary advanced imaging

Not providing supportive treatment

FURTHER QUESTIONS

"When would the X-ray become positive?"

"What other causes of limp would you consider?"

"When would you get an MRI?"

CLINICAL SCENARIOStandard

Scenario 2: Proximal Tibial Fracture with Progressive Valgus

CLINICAL PROMPT

"You are seeing an 8-year-old boy in clinic 12 months after he sustained a proximal tibial metaphyseal fracture that was treated in a cast. The fracture has healed but the parents are worried because his leg has become progressively bowed outwards. Examination confirms a 12 degree valgus deformity. How would you manage this?"

PRACTICAL APPROACH

This is a classic presentation of Cozen's phenomenon or Cozen's fracture. This is a well-described complication of proximal tibial metaphyseal fractures in children, where progressive valgus deformity develops 6-18 months after the fracture heals. The mechanism is not fully understood but may relate to asymmetric growth stimulation or tethering by the intact fibula. The key management point is that this deformity typically self-corrects with continued growth and should not be surgically corrected prematurely. I would reassure the parents that while the valgus is concerning, it is an expected phenomenon after this injury and spontaneous correction occurs in 85% or more of cases by skeletal maturity. I would follow this patient clinically and radiographically every 6-12 months to document the expected gradual correction. I would only consider surgical correction such as a corrective osteotomy if significant deformity persists at or near skeletal maturity.

KEY CLINICAL POINTS

Cozen's phenomenon: expected after proximal tibial metaphyseal fracture

Develops 6-18 months post-injury

Self-corrects in most cases by skeletal maturity

Do not perform early corrective surgery

Reassure parents and observe

COMMON PITFALLS

Performing early corrective osteotomy

Not recognizing Cozen's phenomenon

Blaming initial treatment for deformity

Over-investigating the valgus

FURTHER QUESTIONS

"What is the mechanism of Cozen's phenomenon?"

"When would you consider surgery?"

"What if this was actually from the initial injury?"

CLINICAL SCENARIOChallenging

Scenario 3: Tibial Spine Fracture

CLINICAL PROMPT

"A 12-year-old girl fell off her bicycle and presents with a swollen, painful right knee. She cannot fully extend her knee. X-ray shows a tibial spine fracture that appears displaced by about 8mm with complete loss of contact. How would you manage this?"

PRACTICAL APPROACH

This is a displaced tibial spine fracture, which is the pediatric equivalent of an ACL injury. Based on the description of complete displacement with loss of contact, this would be classified as a Meyers-McKeever Type III fracture. The inability to extend the knee and the tense hemarthrosis are typical findings. Management of Type III tibial spine fractures requires surgical intervention as these do not heal with non-operative management due to the complete displacement. My surgical options would include arthroscopic or open reduction and internal fixation. The fixation options include suture fixation through bone tunnels or screw fixation, avoiding the physis. Sometimes the intermeniscal ligament can block reduction and must be cleared. Pre-operatively I would obtain a CT scan to better define the fragment size and comminution. After reduction and fixation, I would immobilize the knee in extension for 4-6 weeks in a brace or cast. Following healing, she would require ACL rehabilitation protocol to regain strength and proprioception. Long-term, outcomes are generally good, though some residual ACL laxity may be present but is usually not symptomatic in pediatric patients.

KEY CLINICAL POINTS

Type III tibial spine = complete displacement

Requires surgical fixation

Arthroscopic or open reduction

Suture or screw fixation options

ACL rehab protocol post-healing

COMMON PITFALLS

Treating Type III non-operatively

Missing intermeniscal ligament block

Not addressing associated injuries

Performing physeal-crossing fixation

FURTHER QUESTIONS

"What is the classic mechanism for tibial spine fracture?"

"How does this relate to ACL injury?"

"What if closed reduction was successful?"

CLINICAL SCENARIOChallenging

Scenario 4: Floating Knee with Rising Pain

CLINICAL PROMPT

"A 10-year-old is brought in after being struck by a car. He has ipsilateral closed femoral shaft and tibial shaft fractures. Six hours after admission the nursing staff report escalating pain and increasing analgesia requirement despite the leg being splinted. How do you proceed?"

PRACTICAL APPROACH

This is a floating-knee injury, a high-energy pattern, and the escalating analgesia requirement is a red flag for acute compartment syndrome rather than simple fracture pain. My immediate priority is the patient's limb and life. I would complete a structured trauma assessment to exclude other injuries, then focus on the leg. I would remove or split any circumferential dressing and assess for the cardinal sign in children, which is increasing analgesia requirement, alongside pain on passive stretch and tense compartments. In children the classic late signs of pulselessness and paraesthesia are unreliable and should not be awaited. If clinical suspicion is high I would not delay for compartment pressure measurement; I would proceed to urgent four-compartment fasciotomy. Definitive management of the floating knee then involves stabilising both levels, typically flexible intramedullary nails for the femur and either nails or a cast for the tibia depending on the pattern and soft tissues. I would document a thorough neurovascular examination, screen for associated knee ligament injury once the acute phase settles, and counsel the family about the higher complication profile of this injury.

KEY CLINICAL POINTS

Floating knee = ipsilateral femoral and tibial fractures = high energy

Rising analgesia requirement is the key paediatric sign of compartment syndrome

Do not wait for pulselessness or paraesthesia in children

Urgent four-compartment fasciotomy if clinically suspected

Stabilise both levels and screen for associated injuries

COMMON PITFALLS

Attributing escalating pain to the fractures alone

Relying on late signs (pulselessness, paraesthesia)

Delaying fasciotomy to obtain pressure readings

Missing associated knee ligament or head/abdominal injury

FURTHER QUESTIONS

"Which signs of compartment syndrome are unreliable in children?"

"How would you stabilise each fracture level?"

"What is the incidence of associated ligament injury in floating knee?"

MCQ Practice Points

Toddler's Fracture Question

Q: A 2-year-old refuses to walk after a fall. X-ray is normal. What is the management? A: Treat as toddler's fracture with cast 3-4 weeks. Clinical diagnosis is sufficient. X-ray may be negative initially.

Cozen's Phenomenon Question

Q: What is the management of progressive valgus 12 months after proximal tibial metaphyseal fracture? A: Observation and reassurance. Cozen's phenomenon self-corrects by skeletal maturity. Do not operate early.

Tibial Spine Classification Question

Q: Which Meyers-McKeever type requires surgical treatment? A: Type III and IV. Type I and II are typically non-operative. Type III is completely displaced and requires fixation.

Floating Knee Question

Q: What is the main complication risk in floating knee injury? A: Compartment syndrome. Floating knee is high energy with highest compartment syndrome risk. Also screen for other injuries.

Acceptable Deformity Question

Q: How much angulation is acceptable in pediatric tibial shaft fractures? A: 10 degrees sagittal, 5 degrees coronal. Younger children tolerate more. Rotation does not remodel.

Intact Fibula Question

Q: What is the risk of tibial shaft fracture with intact fibula? A: Valgus deformity. Intact fibula acts as tether, preventing shortening but may cause progressive valgus.

Guidelines, Registries & Global Practice

Global Epidemiology

Tibia/fibula fractures are among the commonest paediatric long-bone injuries worldwide
Bimodal pattern: toddlers (low-energy twisting) and adolescents (sport, road traffic)
Male predominance roughly 2:1 across most published cohorts
Mechanism shifts by setting: trampolines, scooters and cycling in high-income regions; falls and road traffic dominate elsewhere

Universal Principles

Age-based remodelling logic is shared across all major training systems (FRCS, FRACS, EBOT, ABOS, DNB/MS)
Toddler's fracture is a clinical diagnosis treated on suspicion regardless of resources
Displaced tibial spine and floating-knee injuries are operative everywhere when expertise allows
Non-accidental injury must be considered in any young, pre-ambulatory child with a tibial fracture

Side-by-Side Society / System Emphasis

Body / System	Toddler's & shaft	Tibial spine	NAI screening
AAOS / POSNA (US)	Cast for low-energy; flexible nails for unstable adolescents	Arthroscopic suture fixation favoured for displaced	Skeletal survey under 2 years per AAP
BOA / BOAST (UK)	Closed treatment first; ESIN for length-unstable	Refer to paediatric ortho/sports knee service	Follow BOAST safeguarding standard
AO Foundation	ESIN entry distal to tubercle apophysis	ORIF/ARIF avoiding physis	Document mechanism vs injury concordance
EFORT / European consensus	Stable angulation thresholds by age	Suture over screw to avoid removal	National safeguarding pathways

Registry & Evidence Notes

No dedicated paediatric tibial-fracture implant registry exists; evidence is cohort/series level
Trauma registries (e.g. national paediatric trauma networks) inform floating-knee and polytrauma outcomes
Flynn criteria remain the common outcome language for flexible-nail series

High- vs Limited-Resource Practice

High-resource: routine arthroscopy, intra-operative imaging, MRI for occult injury, guided-growth implants
Limited-resource: closed reduction and casting prioritised; open reduction when arthroscopy unavailable
Telemedicine and serial radiographs substitute for advanced imaging where access is constrained
Outcomes for closed-treatable patterns remain excellent regardless of setting

PEDIATRIC TIBIAL FRACTURES

Clinical summary

Toddler's Fracture

•Age 9 months to 3 years
•Spiral tibia, often occult on X-ray
•Clinical diagnosis - treat if suspected
•Cast 3-4 weeks, excellent prognosis

Cozen's Phenomenon

•Progressive valgus after proximal tibial metaphyseal fracture
•Develops 6-18 months post-injury
•Self-corrects by skeletal maturity
•DO NOT operate early

Tibial Spine

•Pediatric ACL equivalent
•Meyers-McKeever I-IV
•Type I-II: non-operative (cast)
•Type III-IV: surgical fixation

Floating Knee

•Ipsilateral femur and tibia fractures
•High energy - look for other injuries
•Highest compartment syndrome risk
•Usually requires surgical stabilization

Acceptable Deformity

•10 degrees sagittal plane
•5 degrees coronal plane
•1-1.5 cm shortening
•Rotation: minimal (doesn't remodel)

Fracture

Age

Key Feature

Treatment

Toddler's fracture

9 months - 3 years

Spiral tibia, often occult

Cast 3-4 weeks

Proximal metaphyseal

3-10 years

Risk of Cozen's valgus

Cast, observe for valgus

Tibial spine

8-14 years

ACL equivalent

Type III = surgical

Shaft fracture

All ages

High remodeling

Cast or flexible nails

Floating knee

Any age

High energy

Surgical stabilization

Complication

Fracture Type

Management

Cozen's valgus

Proximal metaphyseal

Observe - self-corrects by maturity

Malunion

Shaft fractures

Remodeling or corrective osteotomy if needed

ACL laxity

Tibial spine

Proper reduction and fixation, ACL rehab

Compartment syndrome

Floating knee, high energy

Urgent fasciotomy

Growth arrest

Physeal injuries

Bar resection or corrective procedures

Nonunion

Rare in children

Operative intervention if occurs

Condition

Typical age

Key discriminator

Pitfall to avoid

Toddler's fracture

9 months - 3 years

Point tibial tenderness, low-energy twist, periosteal reaction at 10-14 days

Calling it 'normal' on day 1 film

Osteomyelitis / septic arthritis

Any

Fever, raised CRP/ESR, warmth, refusal to move joint

Casting an infected limb

Non-accidental injury

Pre-ambulatory or inconsistent history

Mechanism-injury mismatch, other injuries on survey

Failing to safeguard a young child

Transient synovitis

3-8 years

Hip-referred pain, recent viral illness, settles quickly

Missing a tibial source of pain

Bone tumour / cyst (pathological)

Any

Pain before injury, lytic lesion, trivial trauma

Treating fracture without imaging the lesion

Cozen's valgus vs true malunion

3-10 years

Cozen's appears 8-19 months after a healed metaphyseal fracture

Blaming initial treatment for late valgus

How to read these cards

Each card below is anchored to a verified PubMed record (PMID and DOI shown). Use the level of evidence and sample size to judge how heavily to lean on a given statement in a viva.

Cozen's Phenomenon: Natural History and Resolution

Papamerkouriou YM, Tsoumpos P, Tagaris G, Christodoulou G • J Child Orthop (2020)

Key Findings:

Retrospective series of 33 children (6 months to 14 years), mean follow-up 8.8 years
15 of 33 developed late valgus between 8 and 19 months (mean onset 12.5 months)
24 of 33 developed tibial elongation; neither finding correlated with age at injury
Maximum valgus subsequently corrected to near the initial post-treatment angle by final follow-up

Clinical Implication: Warn families that late valgus is common after proximal tibial metaphyseal fractures and reassure them that spontaneous correction is the expected course.

Limitation: Single-centre retrospective study with modest numbers and no control group.

Verify on PubMed (PMID 32582389)

Guided Growth for Persistent Cozen's Deformity

Morin M, Klatt J, Stevens PM • Strategies Trauma Limb Reconstr (2018)

Key Findings:

Largest reported series (19 patients, 24 Cozen's phenomena) treated with medial proximal tibial guided growth
Corrective osteotomy abandoned because of frequent recurrent valgus
Mechanical axis and medial proximal tibial angle corrected in all but one patient
Five recurrences after implant removal; managed by repeat or retained metaphyseal screw

Clinical Implication: Reserve intervention for deformity that fails to resolve; guided growth (hemiepiphysiodesis) is preferred over osteotomy when surgery is genuinely needed.

Limitation: Retrospective series, no control cohort, variable follow-up.

Verify on PubMed (PMID 29549568)

Tibial Eminence Fractures: Surgical Outcomes Systematic Review

Limone B, Zambianchi F, Cacciola G, Seracchioli S, Catani F, Tarallo L • Children (Basel) (2023)

Key Findings:

Systematic review of 12 studies of operatively treated Meyers-McKeever type II-IV fractures
Open reduction showed higher Tegner/Lysholm scores and less arthrofibrosis than arthroscopic fixation
Arthroscopic suture fixation outperformed arthroscopic screw fixation on functional scores
Screw fixation carried the highest rate of implant removal

Clinical Implication: Suture-based fixation is a sound default for displaced tibial spine fractures; counsel that implant removal is more likely with screws.

Limitation: Heterogeneous pooled retrospective data; no randomised comparison.

Verify on PubMed (PMID 37628378)

Arthroscopic Fixation Techniques for Pediatric Tibial Eminence Fractures

Li C, Huang X, Yang Q, Luo Y, Li J, Ye S, Lu W, Zhang X, You T • Front Pediatr (2024)

Key Findings:

Narrative review confirming arthroscopic reduction as the contemporary standard for surgical TEFs
Anchor, suture and screw constructs gave broadly comparable clinical and radiographic results
Suture/anchor techniques minimise physeal damage and are favoured in skeletally immature knees
Higher-quality comparative studies are still needed to define the optimal construct

Clinical Implication: Choose the fixation construct that achieves stable reduction while sparing the physis; technique choice is driven by surgeon experience and fragment quality.

Limitation: Narrative review without pooled statistics or quality grading.

Verify on PubMed (PMID 38596248)

Titanium Elastic Nails for Pediatric Tibial Shaft Fractures

Sankar WN, Jones KJ, Horn BD, Wells L • J Child Orthop (2007)

Key Findings:

19 consecutive children (mean age 12.2 years) with unstable tibial shaft fractures treated with TENs
All united at a mean of 11 weeks; final mean angulation 2 degrees sagittal, 3 degrees coronal
No leg-length discrepancy or physeal arrest; entry-site irritation in 26 percent
12 excellent, 6 satisfactory and 1 poor result by Flynn criteria

Clinical Implication: Elastic stable intramedullary nailing is safe and effective for unstable shaft fractures in older children, with rapid union and few major complications.

Limitation: Small single-centre retrospective cohort.

Verify on PubMed (PMID 19308521)

Adolescent Tibial Shaft Fractures: Treatment Outcomes and Risk Factors

Thabet AM, Craft M, Pisquiy J, Jeon S, Abdelgawad A, Azzam W • Injury (2021)

Key Findings:

52 patients aged 10-18 years treated by ESIN, interlocking nail, plate, external fixator or cast
No significant difference in union rate between fixation methods
Open fractures had longer time to union and a 5.5-fold higher complication risk
Heavier body weight correlated with lower radiographic union scores at 12 weeks

Clinical Implication: No single method fits all adolescents; soft-tissue status and body weight matter more than the specific implant chosen.

Limitation: Single-centre retrospective comparison with limited numbers per subgroup.

Verify on PubMed (PMID 34862039)

Occult Toddler's-Type Tibial Fractures

Swischuk LE, John SD, Tschoepe EJ • Pediatr Radiol (1999)

Key Findings:

Described subtle, easily missed occult tibial fractures in infants and young children
Radiographic findings parallel the classic spiral toddler's fracture of Dunbar
Knowledge of mechanism plus focused exam allows confident diagnosis
Reinforces that initial radiographs are frequently unremarkable

Clinical Implication: A normal initial radiograph does not exclude a toddler's-type fracture; correlate with mechanism and point tenderness.

Limitation: Retrospective radiographic case series.

Verify on PubMed (PMID 9880607)

Foundational Classification & Description (Historical)

Guideline

Meyers MH & McKeever FM; Cozen L; Dunbar JS et al. • J Bone Joint Surg Am / J Can Assoc Radiol (1953-1964)

Key Findings:

Meyers-McKeever (1959/1970) defined the tibial spine fracture classification still used today
Cozen (1953) first described post-traumatic proximal tibial valgus
Dunbar et al. (1964) coined the 'toddler's fracture' as a childhood accidental spiral tibial fracture
These remain the eponymous source descriptions for the entities on this page

Clinical Implication: Quote the eponyms accurately in vivas; the modern evidence above refines, but does not replace, these original descriptions.

Limitation: Historical descriptive works predating modern levels-of-evidence grading.

Body / System

Toddler's & shaft

Tibial spine

NAI screening

AAOS / POSNA (US)

Cast for low-energy; flexible nails for unstable adolescents

Arthroscopic suture fixation favoured for displaced

Skeletal survey under 2 years per AAP

BOA / BOAST (UK)

Closed treatment first; ESIN for length-unstable

Refer to paediatric ortho/sports knee service

Follow BOAST safeguarding standard

AO Foundation

ESIN entry distal to tubercle apophysis

ORIF/ARIF avoiding physis

Document mechanism vs injury concordance

EFORT / European consensus

Stable angulation thresholds by age

Suture over screw to avoid removal

National safeguarding pathways

Type	Description	Displacement	Treatment
Type I	Minimal displacement	Less than 3mm	Extension cast 4-6 weeks
Type II	Anterior hinge intact	Anterior elevation	Attempt closed reduction
Type III	Complete displacement	No contact	Surgical fixation
Type IV	Comminuted fragment	Multiple fragments	Surgical fixation

Type	Description	Displacement	Treatment
Type I	Minimal displacement	Less than 3mm	Extension cast 4-6 weeks
Type II	Anterior hinge intact	Anterior elevation	Attempt closed reduction
Type III	Complete displacement	No contact	Surgical fixation
Type IV	Comminuted fragment	Multiple fragments	Surgical fixation