Treatment of Toddler's Fracture
Conservative management with removable immobilization (controlled ankle motion boot or short leg back slab) for 3-4 weeks is the optimal approach, with no routine orthopedic follow-up or repeat radiographs needed for uncomplicated cases. 1, 2
Diagnosis Confirmation
- Clinical diagnosis is sufficient - toddler's fracture can be diagnosed based on history (twisting injury while walking/stumbling) and examination (tenderness over distal tibia, refusal to bear weight) even without initial radiographic evidence 1, 3
- Initial radiographs may appear normal in up to 39% of cases, but 93% show robust periosteal reaction on follow-up imaging 2
- If clinical suspicion is high with negative initial films, treat presumptively as toddler's fracture 1, 3
Immobilization Method
Preferred options:
- Controlled ankle motion (CAM) boot - allows faster return to weight-bearing (average 2.5 weeks vs 2.8 weeks with casting) 2
- Short leg back slab (posterior splint) - fewer complications and can be removed by family 1
Key advantages of removable immobilization:
- Associated with fewer complications than circumferential casting 1
- Can be removed by family or primary care physician 1
- No difference in fracture stability or displacement rates compared to casting 2
Duration: 3-4 weeks, though 98% of children return to weight-bearing by 4 weeks regardless of immobilization type 2
Follow-Up Requirements
Routine orthopedic follow-up is NOT needed for most children with straightforward toddler's fractures 1
Radiographic monitoring:
- Follow-up radiographs are unnecessary for treatment planning - no radiographs in follow-up were noted to affect treatment decisions 2
- These fractures are universally stable with no documented displacement regardless of immobilization type (including 7 cases with no immobilization) 2
Reattendance rates: Only 17% of patients represent to emergency department within 6 months, with no significant difference between immobilized (17%) and non-immobilized (13%) groups 4
Critical Safeguarding Consideration
Always assess for inflicted injury (non-accidental trauma) when red flags are present 5:
- Inconsistent or absent history of trauma
- Delay in seeking care
- Multiple injuries at different stages of healing
- Fracture pattern inconsistent with developmental stage
Skeletal survey indications for toddler's fracture:
- NOT necessary in children 9-11 months old with distal radius/ulna buckle fracture or toddler's fracture from reported fall while cruising/walking 6
- Consider in children <12 months without clear trauma history (except ambulatory children with toddler's fracture) 6
Clinical Pitfalls to Avoid
- Don't over-immobilize: Circumferential casting offers no stability advantage and increases complication risk 1, 2
- Don't order routine follow-up imaging: Radiographs don't change management in uncomplicated cases 2
- Don't automatically refer to orthopedics: Primary care management is appropriate for typical presentations 1
- Don't dismiss cases with normal initial radiographs: Clinical diagnosis with presumptive treatment is valid 3