Pain in a 2-year-old girl who refuses to bear weight

Toddler's fracture is a term used to describe a nondisplaced spiral, oblique fracture of the distal tibial metadiaphysis caused by a rotational force to the foot and lower leg.1,2 Therefore, patients may also present with fractures of the foot.1 Presentation of the patient for evaluation is usually... Full description

Toddler's fracture is a term used to describe a nondisplaced spiral, oblique fracture of the distal tibial metadiaphysis caused by a rotational force to the foot and lower leg.1,2 Therefore, patients may also present with fractures of the foot.1 Presentation of the patient for evaluation is usually delayed because clinical symptoms are mild and detection is difficult on plain radiographs.1 A toddler's fracture is a common accidental injury in young children aged 9 months to 3 years.3 Clinicians must be able to recognize and treat toddler's fracture and use clinical judgment to assess a nonaccidental etiology.1 Patients typically present with pain and a refusal to bear weight or a limp.1 Fractures may not be detectable on initial plain radiographs. Oblique plain radiographs and scintigraphs are usually not needed and may expose young patients to unnecessary radiation.2 Digital radiographs have been shown to complement the plain radiographs and have a 65% detection rate of toddler's fractures in patients who at first had normal plain radiographic findings.3 Findings on digital radiographs may also provide reassurance to the parents and help to avoid further diagnostic studies.3 Additionally, if findings on the digital radiographs appear normal, a digital inversion of gray scale may aid detection of the fracture line.3 Treatment for nondisplaced fractures is usually with a long leg cast with the knee slightly fl exed, followed by a short leg cast until healed.4 Displaced fractures are casted the same way, with the displacement reduced under conscious sedation in the ED and the reduction confirmed on AP and lateral radiographs.4 To avoid any delay in treatment, a presumptive diagnosis of toddler's fracture should be given to patients who have normal radiographic findings, a history of acute injury, and a limp, or refusal to walk.2 This will lessen the risk of worsening the fracture and reduce the irritability of the patient.2 While it is important to have a high index of suspicion for child abuse, an isolated finding of a toddler's fracture does not indicate abuse.2 Parents should be educated about constitutional symptoms and about what to do if symptoms are not relieved after 24 hours in order to ensure that the patient does not have an underlying infection.2 Conclusion Toddler's fracture may initially manifest in a primary or emergency care setting.