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Three Part Question

In [toddler who is not weight bearing after a minor trauma whose xrays of tibia does not show a fracture] Should [above knee POP be applied] For [presumed toddler's fracture]

Clinical Scenario

12 months old boy tried to walk and fell over. He was unable to weight bear. Examination revealed mild tenderness over the distal tibia and xrays of tibia and fibula showed no fracture.
You wonder whether you should treat him in above knee plaster for presumed toddler's fracture.

Search Strategy

Cochrane database of systemic review and pubmed
Toddler's fracture AND distal tibial metaphysis fracture AND plaster

Search Outcome

103 papers found and 4 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Matthew F.Halsey etal 2001 USA	59 children younger than 6 years who sustained a traumatic injury to the leg.	Retrospective	Detection of toddle's fracture in followup	41% 16/39	Small number Inclded 4 - 5 years
			differentiating characteristics to diagnose toddler's fracture	No particular characteristic was found to predict outcome
BP Sharavat, SN Harrop, TP Kane 1996 UK	21 children between 9 months and 3 years with the diagnosis of toddler's fracture.	Retrospective study	Missed fracture	6/21 28%	Small number No statistical analysis
			History and nature of trauma	9/21 definite history of trauma, 10/21 trivial injury, 2/21 no history of injury
			Initial diagnosis and treatment	11/21 definite fracture, 4/41 possible fracture,6/21 soft tissue injury
Milton Tenenbein, Martin H. Reed, G. Brian Black 1990 Canada	37 children with the diagnosis of toddler's fracture	Retrospective	Detection of fracture at follow-up	5/37	Small number No statistical analysis
			physical findings suggesting a fracture	24/37 had point tenderness, 2/37 swelling and increased localised temperature,11/37 no local finding
JS Dunbar etal 1964 Canada	7 children (9 months to 3 years old) with the diagnosis of toddler's fracture	Retrospective	Fracture detection at follow up	4/7	No statistical analysis
			common clinical finding	Unable to weight bear and localized tenderness

Comment(s)

It appears that higher proportion(upto 41%) of patients with normal initial xrays may be subsequently shown to have a toddler's fractue. Most studies(3/4) used plaster immobilisation if initial xray was normal.The inability to bear weight proved to be the most sensitive for toddler's fracture, it is not at all specific. Localised Tenderness was 71% sensitive and 67% specific.

Clinical Bottom Line

In children with the clear history of trauma who are unable to weight bear, an above knee plaster shoulder should be applied.

References

1. Matthew F. Halsey Toddler's Fracture: Presumptive Diagnosis and Treatment Lippincott Williams & Wilkins 2001, 152-156
2. BP Shravat Toddler's fracture J Accid Emerg Med 1996, 59-61
3. Milton Tenenbein The Toddler's Fracture Revisited American Journal of Emergency Medicine 1990, 208-211
4. J S Dunbar Obscure Tibial Fracture of Infants- The Toddler's Fracture Journal De L'association Canadienne Des Radiologistes September 1964, 136-144