What are the typical presentation and management of a spiral tibial fracture in a 2-year-old?

From the Guidelines

Spiral tibial fractures in 2-year-olds typically present as toddler's fractures, characterized by limping, refusal to bear weight, and localized pain or tenderness over the tibia, and are usually managed conservatively with immobilization and analgesia. These injuries often result from low-energy rotational forces during normal play activities. The diagnosis is based on a history of trauma and focal pain on palpation, and is confirmed with radiographic studies, although initial radiographs may appear normal 1. Management is generally conservative with immobilization using a long leg cast for 3-4 weeks, followed by a short leg cast or walking boot for an additional 2-3 weeks.

Key Considerations

• Analgesia with weight-appropriate doses of acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours) is recommended for pain control.
• Follow-up imaging at 7-10 days may reveal callus formation, confirming the diagnosis 1.
• Prognosis is excellent with complete healing expected within 6-8 weeks without long-term complications.
• Children this age have significant remodeling potential, so perfect anatomic alignment is not necessary.
• Non-accidental trauma should always be considered in the differential diagnosis, particularly when the history is inconsistent with the injury pattern or when additional concerning injuries are present.

Diagnostic Approach

• Radiographs of the lower extremities are often normal, with reports of fracture incidence ranging from 4% to 20% 1.
• Spiral tibial fractures are by far the most common fractures found in children <4 years of age presenting with nonlocalized limp or refusal to bear weight.
• If initial imaging is normal but symptoms persist, follow-up radiographs or radiographs of areas besides the tibia/fibula may be useful 1.

From the Research

Typical Presentation of Spiral Tibial Fracture in a 2-year-old

• A spiral tibial fracture, also known as a toddler's fracture, typically presents with the child limping or refusing to walk 2, 3.
• Tenderness at the fracture site is common, but may be difficult to elicit in young children 2.
• The fracture is often caused by a twisting injury while tripping, stumbling, or falling 2.

Diagnosis of Spiral Tibial Fracture

• The diagnosis of a toddler's fracture is typically made clinically, and may be confirmed with radiographs 2.
• Initial radiographs may appear normal, and additional imaging or investigations may be necessary to confirm the diagnosis 3.
• A detailed history and examination are crucial in diagnosing a toddler's fracture 3.

Management of Spiral Tibial Fracture

• The treatment of a toddler's fracture is usually conservative, with immobilization of the affected limb 2, 3.
• A controlled ankle motion boot or a short leg back slab are preferred methods of immobilization, as they are associated with fewer complications and can be removed by the family or family physician 2.
• Analgesia and immobilization are the mainstays of treatment, with follow-up in a fracture clinic recommended in some cases 3.
• The type of immobilization used may not affect the outcome, and radiographic follow-up may be unnecessary for treatment planning 4, 5.