Toddler's fractures are bone fractures of the distal (lower) part of the shin bone (

tibia The tibia (; ), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outside of the tibia); it connects ...

) in toddlers (aged 9 months-3 years) and other young children (less than 8 years). The fracture is found in the distal two thirds of the tibia in 95% of cases, is undisplaced and has a spiral pattern. It occurs after low-energy

trauma Trauma most often refers to: * Major trauma, in physical medicine, severe physical injury caused by an external source * Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic i ...

, sometimes with a rotational component.

Pathophysiology

The proposed mechanism involves

shear stress Shear stress, often denoted by (Greek: tau), is the component of stress coplanar with a material cross section. It arises from the shear force, the component of force vector parallel to the material cross section. ''Normal stress'', on the ...

and lack of displacement due to the

periosteum The periosteum is a membrane that covers the outer surface of all bones, except at the articular surfaces (i.e. the parts within a joint space) of long bones. Endosteum lines the inner surface of the medullary cavity of all long bones. Structu ...

that is relatively strong compared to the elastic bone in young children.

Diagnosis

Typical symptoms include pain, refusing to walk or bear weight and limping -

bruising A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur clos ...

and deformity are absent. On

clinical examination In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patie ...

, there can be warmth and swelling over the fracture area, as well as pain on bending the foot upwards (

dorsiflexion Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relativ ...

). The initial radiographical images may be inconspicuous (a faint oblique line) and often even completely normal. After 1–2 weeks however,

callus A callus is an area of thickened and sometimes hardened skin that forms as a response to repeated friction, pressure, or other irritation. Since repeated contact is required, calluses are most often found on the feet and hands, but they may o ...

formation develops. The condition can be mistaken for

osteomyelitis Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the ...

transient synovitis Transient synovitis of hip (also called toxic synovitis; see below for more synonyms) is a self-limiting condition in which there is an inflammation of the inner lining (the synovium) of the capsule of the hip joint. The term irritable hip refer ...

or even child abuse. Contrary to CAST fractures, non-accidental injury typically affect the upper two-thirds or midshaft of the tibia. Other possible fractures in this area, occurring in the cuboid, calcaneus, and

fibula The fibula or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. Its upper extremity i ...

, can be associated or can be mistaken for a toddler's fracture. In some cases, an internal oblique radiography and radionuclide imaging can add information to anterior-posterior and lateral views. However, since treatment can also be initiated in the absence of abnormalities, this appears to have little value in most cases. It could be useful in special cases such as children with

fever Fever, also referred to as pyrexia, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using val ...

, those without a clear trauma or those in which the diagnosis remains unclear. Recently,

ultrasound Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...

has been suggested as a helpful diagnostic tool.

Treatment

Treatment consist of a long leg

orthopedic cast An orthopedic cast, or simply cast, is a shell, frequently made from plaster or fiberglass, that encases a limb (or, in some cases, large portions of the body) to stabilize and hold anatomical structures—most often a broken bone (or bones), in ...

for several weeks.

History

The condition was initially recognised by Dunbar and co-workers in 1964. A new terminology has been proposed, which defines toddler's fracture as a subset of childhood accidental spiral tibial (CAST) fractures.

References

External links

{{Fractures Bone fractures Pediatrics