TODDLER'S FRACTURE
Occult Spiral Tibia | Clinical Diagnosis | 9 Months to 3 Years
KEY DIAGNOSTIC FEATURES
Critical Must-Knows
- Age 9 months to 3 years - child must be ambulatory (walking age)
- X-ray is OFTEN NEGATIVE initially - treat clinically if suspected
- Spiral fracture pattern on distal to mid tibial shaft
- Repeat X-ray at 2 weeks shows periosteal reaction confirming fracture
- Consider NAI if pattern inconsistent with developmental stage
Examiner's Pearls
- "Negative X-ray does NOT rule out toddler's fracture
- "Bone scan or MRI only if diagnosis uncertain and not improving
- "3-4 weeks in below-knee or above-knee cast
- "Look for spiral line on oblique view if AP/lateral negative
Critical Exam Concepts
Clinical Diagnosis
X-ray negative in 50%. If clinical suspicion high (limping walking-age toddler, point tenderness tibia, no other cause), treat with cast even if X-ray negative. Repeat X-ray at 2 weeks shows healing.
Age is Critical
9 months to 3 years. Child must be ambulatory (walking). Before walking = suspicious for NAI. After 3 years = other diagnoses more likely. The classic patient just started walking.
X-ray Interpretation
Look for subtle spiral. Often best seen on internal oblique view. Non-displaced, minimal periosteal reaction initially. May only see soft tissue swelling or subtle cortical irregularity.
NAI Differential
Consider abuse if atypical. Spiral tibial fracture in non-ambulatory child (not yet walking) raises suspicion for NAI. Document developmental milestones carefully.
Toddler's Fracture Quick Reference
| Feature | Typical Finding | Red Flag |
|---|---|---|
| Age | 9 months to 3 years (walking) | Non-ambulatory = NAI concern |
| Mechanism | Low-energy twisting fall | High-energy = atypical |
| X-ray | Often negative initially | Multiple fractures = NAI |
| Location | Distal to mid tibial shaft | Metaphyseal = bucket handle (NAI) |
| Pattern | Spiral/oblique, non-displaced | Transverse = higher energy |
SPIRALToddler's Fracture Features
Memory Hook:SPIRAL fracture that's SUBTLE - treat clinically!
RED FLAGSWhen to Suspect NAI
Memory Hook:RED FLAGS in pediatric fractures must be documented!
CASTToddler's Fracture Management
Memory Hook:CAST the limping toddler - don't wait for positive X-ray!
Overview and Epidemiology
Why This Age?
Walking age but immature gait. Toddlers just learning to walk have an unsteady gait and are prone to twisting falls. The tibia is relatively weak compared to the forces generated. After age 3-4, gait matures and coordination improves.
Epidemiology
- Peak age 9 months to 3 years
- Must be ambulatory (started walking)
- Boys slightly more common
- Common pediatric fracture
- Often presents to ED or GP
Mechanism
- Low-energy twisting injury
- Running and stumbling
- Playground falls
- Often unwitnessed
- Child cannot describe mechanism
Anatomy and Biomechanics
Pediatric Tibial Shaft
Location: Fracture typically occurs in the distal third to middle third of the tibial diaphysis.
Why spiral? Rotational force with fixed foot creates spiral pattern. The periosteum is thick in children and often remains intact, limiting displacement.
Blood supply: Pediatric tibia has excellent blood supply. Union is rapid (3-4 weeks) compared to adults.
Classification and Variants
Classic Toddler's Fracture
Location: Distal to mid tibial diaphysis.
Pattern: Spiral or oblique, non-displaced or minimally displaced.
Key feature: The fracture is often subtle or invisible on initial X-ray. Look carefully for a faint spiral line or cortical discontinuity.
Clinical Assessment
History
- Child limping or refusing to walk
- Often no witnessed injury
- Low-energy mechanism if observed
- No significant trauma
- Developmental milestones (is child walking?)
Examination
- Point tenderness along tibial shaft
- Minimal or no swelling
- Refuses to bear weight
- No obvious deformity
- Normal neurovascular status
Clinical Diagnosis
Trust your clinical exam. A walking-age toddler who refuses to bear weight, has point tenderness over the tibia, and has no other explanation (hip, knee, foot pathology ruled out) likely has a toddler's fracture even if X-ray is negative. TREAT CLINICALLY.
Must Rule Out Other Causes
Before diagnosing toddler's fracture, ensure you have assessed: hip (septic joint, Perthes, transient synovitis), knee (injury, infection), foot (foreign body, injury), soft tissue (bruising, infection). A limping child workup may include inflammatory markers if infection suspected.
Investigations
X-ray Protocol
Standard views: AP and lateral tibia/fibula (full length including ankle and knee).
Internal oblique view: May reveal the spiral fracture line when AP/lateral are negative.
What to look for: Subtle spiral line, cortical irregularity, soft tissue swelling. The fracture is often NON-DISPLACED.
| View | Finding | Sensitivity |
|---|---|---|
| AP tibia | May show spiral line | Variable |
| Lateral tibia | Often negative | Low |
| Internal oblique | Best for spiral | Higher |
| 2-week follow-up | Periosteal reaction | High |
Management
Treat Clinically if Suspected
Do not wait for positive X-ray to treat. If clinical suspicion is high (limping walking-age toddler, tibial tenderness, low-energy mechanism), apply a cast. The child will improve, and follow-up X-ray confirms the diagnosis.
Cast Treatment
Options: Above-knee cast (AKC) or below-knee cast (BKC). Both are acceptable.
AKC advantages: Controls rotation better. Tolerated well by toddlers (they adapt quickly).
BKC advantages: Lighter, allows knee motion.
Duration: 3-4 weeks. Healing is rapid in this age group.
Follow-up: X-ray at 2-3 weeks to confirm healing. Remove cast when callus visible.
Parental Counseling
Explain to parents: "We suspect a minor fracture that may not show on today's X-ray. We will treat with a cast for 3-4 weeks. A repeat X-ray will confirm healing. Your child will be walking normally again soon."
Surgical Considerations
Surgery NOT Required
Toddler's fractures are almost universally treated non-operatively. Surgical intervention is not indicated for typical toddler's fracture. Cast immobilization for 3-4 weeks achieves 100% union.
Why no surgery? Non-displaced fracture, excellent pediatric healing, thick periosteum maintains alignment, no instability.
Complications
Complications of Toddler's Fracture
| Complication | Incidence | Management |
|---|---|---|
| Delayed diagnosis | Common | Repeat X-ray at 2 weeks |
| Cast-related issues | Occasional | Skin checks, cast modification |
| Nonunion | Extremely rare | Almost never occurs in children |
| Growth disturbance | None | Fracture is diaphyseal, not physeal |
| Long-term disability | None | Excellent prognosis |
Excellent Prognosis
Toddler's fracture has an excellent prognosis. Union is virtually 100%. There are no long-term sequelae. The child returns to normal function within weeks.
Follow-Up Protocol
Toddler's Fracture Follow-Up
Clinical assessment, X-ray (may be negative), apply cast if suspected. Document developmental milestones.
Optional - check cast fit if any concerns. Phone follow-up acceptable.
X-ray through cast or after cast removal. Look for periosteal reaction / callus confirming fracture healing.
Remove cast once callus visible and child comfortable. Allow gradual return to walking.
Child should be walking normally. No further follow-up needed unless concerns.
Outcomes and Prognosis
Key Prognostic Points
Union: Virtually 100% - nonunion essentially does not occur.
Remodeling: Not needed - fracture is usually non-displaced.
Growth: No growth disturbance - fracture is diaphyseal, not physeal.
Function: Complete return to normal gait and activity.
Special Considerations
When to Consider Non-Accidental Injury
Red flags:
- Child is non-ambulatory (not yet walking)
- Spiral fracture in infant
- Inconsistent or changing history
- Delayed presentation
- Other injuries in different healing stages
Action: If NAI suspected, full skeletal survey, child protection referral, thorough documentation.
Evidence Base and Key Studies
Dunbar et al. - Original Description
- First described toddler's fracture
- Spiral tibial fracture in walking children 9 months to 3 years
- Often occult on initial X-ray
- Excellent prognosis with casting
Halsey et al. - Clinical Diagnosis
- Reviewed X-ray sensitivity for toddler's fracture
- Initial X-ray negative in up to 50%
- Repeat X-ray at 2 weeks shows periosteal reaction
- Clinical diagnosis validated
Schuh et al. - Cast Type Comparison
- Compared above-knee to below-knee casting
- Both effective for toddler's fracture
- No difference in healing time
- BKC may be more convenient
John et al. - MRI Utility
- MRI can detect occult fractures
- Shows bone marrow edema before X-ray changes
- Rarely needed in practice
- Useful for atypical cases
Mellick et al. - Cuboid Toddler's
- Described cuboid bone fracture in toddlers
- Similar mechanism to tibial toddler's
- May be occult on X-ray
- Termed 'cuboid toddler's fracture'
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Classic Presentation
"An 18-month-old boy presents with acute onset limping. Mum reports he was playing in the backyard and then started crying and refusing to walk. He is afebrile. X-rays of the tibia are normal. How would you manage this?"
Scenario 2: NAI Consideration
"A 7-month-old infant presents with a spiral tibial fracture. The parents report she rolled off the couch and hasn't been moving her leg since. She is not yet walking. What are your concerns?"
Scenario 3: Failure to Improve
"A 22-month-old was treated for suspected toddler's fracture in a cast 2 weeks ago after presenting with a limp and negative X-ray. On review today, the parents report she is still not walking. Repeat X-ray is also normal. What are your next steps?"
MCQ Practice Points
Age Range Question
Q: What is the typical age range for toddler's fracture? A: 9 months to 3 years. The child must be ambulatory (walking age). Before walking age, consider NAI.
X-ray Sensitivity Question
Q: What percentage of toddler's fractures have a negative initial X-ray? A: Approximately 50%. Repeat X-ray at 2 weeks shows periosteal reaction, confirming the diagnosis.
Treatment Question
Q: How should you manage a suspected toddler's fracture with negative X-ray? A: Apply a cast and treat clinically. A negative X-ray does not rule out the diagnosis. Treat based on clinical suspicion.
Fracture Pattern Question
Q: What is the typical fracture pattern in toddler's fracture? A: Spiral or oblique, non-displaced, distal to mid tibial shaft. The spiral pattern results from rotational force.
Cast Duration Question
Q: How long should a toddler's fracture be casted? A: 3-4 weeks. Healing is rapid in this age group.
NAI Concern Question
Q: In what circumstance is a spiral tibial fracture concerning for NAI? A: In a non-ambulatory child (not yet walking). Toddler's fracture requires the child to be walking. Spiral fracture in a non-walker raises abuse concern.
Australian Context
Clinical Practice
- Common presentation to EDs and GPs
- Clinical diagnosis well-accepted
- Cast treatment standard
- Excellent outcomes expected
Child Protection
- Mandatory reporting laws apply
- Document developmental milestones
- Low threshold for NAI workup if atypical
- Child protection teams in major hospitals
TODDLER'S FRACTURE
High-Yield Exam Summary
Key Features
- •Age 9 months to 3 years (walking)
- •Spiral/oblique tibial shaft fracture
- •Low-energy twisting mechanism
- •X-ray often negative initially
Clinical Diagnosis
- •Point tenderness over tibia
- •Refuses to bear weight
- •No visible deformity
- •Treat even if X-ray negative
Treatment
- •Above or below knee cast
- •3-4 weeks duration
- •Repeat X-ray at 2 weeks
- •100% union rate
NAI Concerns
- •Non-ambulatory child = red flag
- •Spiral fracture in infant suspicious
- •Inconsistent mechanism
- •Document developmental stage
Prognosis
- •Excellent - complete recovery
- •No growth disturbance
- •No long-term sequelae
- •Normal gait by 4-6 weeks