What is the management for a buckle fracture of the proximal tibia in a 23-month-old?

Management of Proximal Tibial Buckle Fracture in a 23-Month-Old Child

A removable knee immobilizer is the recommended treatment for a proximal tibial buckle fracture in a 23-month-old child, as it provides adequate stabilization while avoiding complications associated with casting and reducing healthcare utilization. 1

Diagnostic Considerations

When evaluating a proximal tibial buckle fracture in a toddler, consider:

• Mechanism of injury (common causes include falls or bouncing activities) 2
• Associated symptoms (pain, limited weight-bearing)
• Radiographic confirmation of buckle deformity without displacement
• Age-appropriate assessment (younger children are more likely to have simple buckle deformities) 2

Treatment Algorithm

Primary Management

1. Immobilization with removable knee immobilizer

   • Provides adequate stabilization without risk of displacement 1
   • Associated with fewer skin complications compared to casting 1
   • Allows for hygiene and skin inspection

2. Duration of immobilization

   • Approximately 3-4 weeks (mean 25.9 days for knee immobilizer) 1, 3
   • Shorter immobilization time compared to long leg casting (27.9 days) 1

3. Follow-up schedule

   • Fewer clinic visits required (mean 2.2 visits) compared to cast treatment (2.6 visits) 1
   • Initial follow-up within 1-2 weeks to ensure proper healing

Additional Considerations

• Pain management

  • Age-appropriate analgesics (acetaminophen)
  • Avoid NSAIDs in children with renal dysfunction 4

• Activity restrictions

  • Limited weight-bearing during immobilization period
  • Gradual return to normal activities after immobilization

Evidence Analysis

The most recent and highest quality evidence from a 2024 study by the Journal of Pediatric Orthopedics demonstrates that removable knee immobilizers are safe and effective for proximal tibial buckle fractures in children 1. This study of 224 pediatric patients showed:

• No fracture displacement in either immobilizer or cast groups
• Skin complications occurred only in the cast group (3.1%)
• Significantly shorter immobilization time with knee immobilizers
• Fewer clinic visits required with knee immobilizers

This approach is further supported by systematic reviews showing that removable splints are effective for buckle fractures, reducing healthcare utilization while maintaining good outcomes 3.

Common Pitfalls and Caveats

• Misdiagnosis: Ensure proper radiographic confirmation of buckle fracture versus other fracture types that may require more aggressive management

• Unnecessary casting: Long leg casting was traditionally used but carries risks of skin complications and requires more healthcare visits 1

• Inadequate follow-up instructions: Parents/caregivers should be educated about:

  • Signs of complications requiring immediate attention
  • Proper application and removal of the immobilizer
  • Expected timeline for recovery

• Failure to consider abuse: In children under 24 months with fractures, consider the possibility of non-accidental trauma, though skeletal survey is generally not indicated for isolated buckle fractures with consistent history 4

Special Considerations for Toddlers

• Proximal tibial buckle fractures in younger children (median age 21 months) are more commonly caused by falls rather than trampoline/bouncing activities 2
• Younger children have better healing potential but may be less compliant with immobilization
• Parent/caregiver education is crucial for successful management

By following this evidence-based approach, proximal tibial buckle fractures in toddlers can be effectively managed with minimal complications and optimal functional outcomes.