Management of Toddler's Tibial Fracture with Heel Pressure Ulcer and Boot Intolerance
Switch immediately to a non-removable cast for this 2-year-old with a nondisplaced distal tibial shaft fracture who has developed a heel pressure ulcer and refuses to wear the CAM boot. The combination of poor compliance with removable immobilization and active skin breakdown necessitates definitive casting that ensures proper immobilization while addressing the pressure injury.
Immediate Immobilization Strategy
Apply a well-padded, above-ankle cast (short leg cast) with meticulous attention to the heel area to provide non-removable immobilization that the child cannot refuse while protecting the existing pressure ulcer 1, 2.
Use extra padding over bony prominences, particularly around the heel ulcer site, creating a window or relief area if the ulcer requires direct wound care access 3.
Consider a windowed cast technique where a removable window is cut over the ulcer site to facilitate wound assessment and treatment between cast changes while maintaining overall immobilization 3.
Ensure the cast extends high enough to prevent removal by the toddler but remains below the knee to allow some knee motion, as toddler's fractures heal reliably with this level of immobilization 1, 4.
Pressure Ulcer Management Concurrent with Casting
Inspect and debride the heel ulcer before cast application, removing any necrotic tissue or callus that could worsen under the cast 3.
Apply appropriate wound dressings that control exudate and maintain a moist healing environment before casting 3.
Plan for cast changes every 1-2 weeks initially to monitor both fracture healing and ulcer progression, as the ulcer requires ongoing assessment 3.
Use static support surfaces (specialized mattress or overlay) when the child is resting to offload the heel and prevent worsening of the pressure injury 3.
Why the CAM Boot Failed and Should Not Be Continued
Removable boots allow non-adherence in toddlers, which leads to inadequate immobilization and can result in delayed union or malunion 5.
The boot clearly caused the pressure ulcer through improper fit or excessive pressure, and continuing its use will worsen the skin breakdown 3.
Two-year-olds lack the cognitive ability to understand the need for continuous boot wear, making compliance impossible without constant parental supervision 3, 1.
The heel pressure ulcer indicates the boot was either ill-fitting or worn incorrectly, and adjusting it will not reliably prevent recurrence in an uncooperative toddler 3.
Fracture Healing Expectations
Nondisplaced distal tibial shaft fractures in toddlers (toddler's fractures) heal reliably with simple immobilization in approximately 3-4 weeks, with union typically occurring around 10 weeks for tibial shaft fractures in this age group 1, 2, 4.
Serial radiographs are not routinely necessary for stable, nondisplaced fractures healing appropriately; repeat imaging should only be obtained if new trauma occurs, pain increases, or neurovascular symptoms develop 6.
Clinical healing (pain-free weight bearing) often precedes radiographic union in young children, and the child's willingness to bear weight is a reliable indicator of healing 1, 4.
Critical Monitoring During Treatment
Assess for compartment syndrome at each visit, though it occurs less frequently in children than adults with tibial fractures 3, 2.
Watch for the "three As" in young children: anxiety, agitation, and increased analgesic requirements, which may indicate developing compartment syndrome when the child cannot articulate pain 3.
Monitor the pressure ulcer healing trajectory with each cast change, ensuring it is improving rather than worsening 3.
Educate parents on cast care and signs of complications including increased pain, fever, foul odor from the cast, or changes in toe color/temperature 2.
Common Pitfalls to Avoid
Do not continue with removable immobilization in an uncooperative toddler, as inadequate immobilization risks delayed union and the pressure ulcer will not heal with continued boot use 5, 1.
Do not apply the cast too tightly, particularly over the heel area, as this can worsen the existing pressure ulcer or create new areas of skin breakdown 3.
Do not assume the fracture requires surgical intervention simply because conservative management with the boot failed; the issue is compliance and skin breakdown, not fracture instability 1, 2, 4.
Do not overlook the possibility of non-accidental injury in any toddler with a fracture, particularly if the history is inconsistent or there are other concerning injuries, though a simple toddler's fracture with a clear mechanism is typically accidental 2, 4.
Avoid prolonged immobilization beyond what is necessary, as this can lead to stiffness, though this is rarely problematic in young children who regain motion quickly 7.