Presumed toddler’s fracture and above knee plaster

Date First Published:
March 12, 2007
Last Updated:
March 16, 2007
Report by:
Claire Summers, Consultant in Emergency Medicine (Trafford General Hospital)
Search checked by:
Muhammad Ahmad, Trafford General Hospital
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
Search Details:
Toddler's fracture AND distal tibial metaphysis fracture AND plaster
Outcome:
103 papers found and 4 were relevant
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Toddler's Fracture: Presumptive Diagnosis and Treatment Matthew F. Halsey 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
Toddler's fracture BP Shravat 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
The Toddler's Fracture Revisited Milton Tenenbein 1990 Canada 37 children with the diagnosis of toddler's fracture Retrospective Detection of fracture at follow-up May-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
Obscure Tibial Fracture of Infants- The Toddler's Fracture J S Dunbar 1964 Canada 7 children (9 months to 3 years old) with the diagnosis of toddler's fracture Retrospective Fracture detection at follow up 04-Jul No statistical analysis
common clinical finding Unable to weight bear and localized tenderness
Author Commentary:
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.
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
  2. BP Shravat. Toddler's fracture
  3. Milton Tenenbein. The Toddler's Fracture Revisited
  4. J S Dunbar. Obscure Tibial Fracture of Infants- The Toddler's Fracture