What is the diagnostic and treatment approach for a 1-year-old with a suspected right foot fracture?

Diagnostic and Treatment Approach for a 1-Year-Old with Suspected Right Foot Fracture

For a 1-year-old with a suspected foot fracture, obtain standard radiographs of the foot (anteroposterior, lateral, and oblique views) for diagnosis, and if confirmed, immobilize with a short leg cast or controlled ankle motion boot for 3-4 weeks with close clinical follow-up.

Critical Initial Consideration: Rule Out Non-Accidental Trauma

Any fracture of the tibia, fibula, or femur in a child under 1 year of age should raise suspicion for physical abuse and warrants careful evaluation. 1

• Fractures in children who are not yet walking are particularly concerning for non-accidental trauma 1
• The child's motor developmental level is a key discriminator—at 1 year of age, most children are just beginning to walk, making the mechanism of injury critical to assess 1
• If the history is inconsistent with the injury pattern, unexplained, or if there are other concerning features (bruising, multiple injuries, developmental delay inconsistent with walking), a complete skeletal survey must be performed 1

Diagnostic Approach

Initial Imaging

Obtain standard three-view radiographs of the right foot (anteroposterior, lateral, and oblique views) as the first-line diagnostic test. 1, 2

• Plain radiographs are the initial imaging modality of choice for suspected pediatric foot fractures 1, 2
• Weight-bearing views are standard in adults but may not be feasible or necessary in a 1-year-old who is refusing to bear weight 2
• Important caveat: Negative initial radiographs do not completely exclude a nondisplaced fracture, particularly in toddlers 1, 3

If Initial Radiographs Are Negative but Clinical Suspicion Remains High

• Treat as a presumed fracture with immobilization and clinical follow-up 3
• Follow-up radiographs at 7-10 days may reveal healing callus that confirms the diagnosis 1, 3
• Bone scintigraphy (Tc-99m bone scan) can be considered if symptoms persist and localization remains unclear, though this requires sedation and is rarely necessary 1
• MRI is rarely needed for simple foot fractures but has higher sensitivity for occult fractures if diagnosis remains uncertain 1, 4

Additional Imaging Considerations

If there is any concern for non-accidental trauma based on history or examination, obtain a complete skeletal survey. 1

• Skeletal survey is recommended in all children under 2 years of age when abuse is suspected 1
• 11-20% of infants being evaluated for abuse have unsuspected fractures detected by skeletal survey 1
• A repeat skeletal survey should be performed 2-3 weeks later if abuse is strongly suspected, as it may identify fractures not seen initially 1

Treatment Approach

Conservative Management (Preferred for Most Pediatric Foot Fractures)

Immobilize with a short leg cast, controlled ankle motion boot, or back slab for 3-4 weeks. 5, 3, 2, 6

• A controlled ankle motion boot or short leg back slab is preferred over a traditional cast because they are associated with fewer complications and can be removed by the family or physician 3
• For very young children who may slip out of shorter casts, a long leg cast may be necessary 5
• Most pediatric fractures heal successfully with non-surgical methods due to higher remodeling capacity and faster healing 6

Immobilization Duration and Follow-Up

For stable fractures: Remove cast after 3-4 weeks with clinical assessment of consolidation. 5, 2

• Radiographic follow-up at 1 week is recommended if the fracture was displaced or reduced to exclude secondary displacement 5
• Further radiographs at 4 weeks to confirm consolidation 5
• Skin complications (especially at the heel) occur in approximately 2% of cases and must be prevented with adequate padding 5

Weight-Bearing

• Weight-bearing should be guided by the child's pain tolerance 2
• Most children will naturally limit weight-bearing as needed 3, 2
• Gradual return to weight-bearing activities with supportive footwear after immobilization 4

When to Consider Orthopedic Referral

Most simple foot fractures in 1-year-olds do not require orthopedic follow-up if properly immobilized and healing appropriately. 3

However, immediate orthopedic consultation is indicated for:

• Displaced fractures beyond the range of age-dependent spontaneous correction 5
• Fractures with coexisting vascular injuries 6
• Open fractures 6
• Physeal (growth plate) fractures that are displaced 6
• Any concern for compartment syndrome 2
• Failed conservative treatment 6

Common Pitfalls to Avoid

• Do not dismiss the possibility of abuse: Any lower extremity fracture in a pre-walking or newly walking child requires careful history and consideration of skeletal survey 1
• Do not assume negative radiographs exclude fracture: Toddler's fractures are frequently occult on initial imaging 1, 3
• Do not use traditional plaster casts when removable boots are available: Boots reduce complications and allow for easier monitoring 3
• Do not forget adequate padding: Skin complications at the heel are preventable with proper technique 5
• Do not over-radiate: Avoid unnecessary CT scans for simple foot fractures 1