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Clinical Features and Management of Children with Toddler's Fracture or Suspected Toddler's Fracture In the Pediatric Emergency Department (PED)

Friday, October 19, 2012
Room 272-273 (Morial Convention Center)
Miriam T. Stewart, B.A., Johns Hopkins School of Medicine, Baltimore, MD and Parul B. Patel, MD, MPH, Pediatric Emergency Department, Children's Memorial Hospital/ Feinberg School of Medicine Northwestern University, Chicago, IL


The diagnosis and management of toddler’s fracture and suspected toddler’s fracture can often be complicated by lack of a clear history, absence of focal findings on exam, and absence of clear evidence on initial x-ray. There is little literature to guide clinicians in deciding whether to splint symptomatic patients whose x-rays are negative in the PED. Our objective is to describe clinical features associated with true toddler’s fracture as well as the PED management and outcomes of patients with toddler’s fracture or suspected toddler’s fracture in order to guide clinical decision-making for these children.


We performed a retrospective chart review of children ages 9-36 months who presented to the PED in 2010 with limp or inability to bear weight, were suspected of having a toddler’s fracture based on history or physical, and underwent radiography of the tibia/fibula. Exclusion criteria were fever, duration of symptoms > 3 days, symptoms localizable to a different area of the leg, diagnosis of different fracture type, history of more than minor trauma, or symptom resolution in the PED. Demographics, history and physical exam (PE), x-ray findings, PED management, follow up data from orthopedics, and outcomes were analyzed using descriptive statistics and univariate regression (STATA version 11.1).


Of 217 patients in this age range who underwent tibia/fibula x-rays during the study period, 59 met inclusion criteria. Median age was 20 months and 68% were male. Twenty-two patients (37.3%) had a final diagnosis of toddler’s fracture. Of these, seventeen (77.3%) had a positive x-ray in the PED and 5 (22.7%) did not have a positive x-ray until orthopedics follow-up. Common mechanisms for toddler’s fracture included simple fall (27.3%), going down a slide (27.3%), and fall from height of less than 3 feet (27.3%). PE findings significantly associated with a final diagnosis of toddler’s fracture were swelling (OR 19.1, 95% CI 2.1-173.4, p=0.009), localized tenderness (OR 3.9, 95% CI 1.2-12.6, p=0.02), and inability to bear weight (OR 10.0, 95% CI 2.5-50.0, p=0.001). Of 22 patients splinted in the PED for clinical or radiographic diagnosis of toddler’s fracture who followed up with orthopedics, only 1 (4.5%) suffered a splint-related complication (heel blister). Two patients with a final diagnosis of toddler’s fracture were not splinted in the PED and followed up with orthopedics due to persistent symptoms. One of these patients was casted and one did not require immobilization.


Swelling, localized tenderness, and inability to bear weight on PE are significantly associated with the final diagnosis of toddler’s fracture. Contrary to expectation, the majority of toddler’s fractures are evident on x-ray in the acute period and the majority of splints applied for this indication in the ED were well tolerated at our institution during the study period.