This material is presented for educational purposes only and does not constitute medical advice. Consult with a board-certified orthopedic surgeon for specific recommendations for your child.  

Introduction

A study by Fox and colleagues at Seattle Children's Hospital studied observation versus long-leg casting for 44 children between 1 and 3 years of age with toddler's fractures.[1] A toddler's fracture is a "nondisplaced spiral fracture of the distal tibial metaphysis occurring in patients 9 months to 3 years old."  Toddler's fractures are so named because of their prevalence in this age group and are known to be stable injuries. Patients were randomized during the first year, and subsequently placed in "preference groups" because of parent reluctance to participate in randomization.

The authors reported that patients treated with observation had faster return to ambulation and that parents were more satisfied with their treatment choice compared to patients treated in a long-leg cast (95.6% vs. 80%). However, patients in treated with observation were more likely to have residual pain at 8 weeks (2/21, 9.5%) compared to patients treated with casting (0/10, 0%). 4 of 14 patients in the cast group (28.6%) and 7 of 30 patients in the observation group (23.3%) were lost to follow-up, limiting study quality.

Perspective

The study confirms what has long been known: that Toddler's fractures are stable injuries and that many patients do not require a long leg (above knee) cast. Just as distal one-third forearm and wrist fractures have not been shown to benefit from above-elbow casting, evidence is lacking that an above-knee cast offers clinical benefits for children with toddler's fractures of the lower tibia.  An above-knee cast immobilizes the knee and impairs walking ability, and the study documents what we would logically expect.

The study does not evaluate the more relevant option.  Short-leg walking casts are used by many practitioners to treat toddler's fractures, offering better pain relief than observation and better walking ability compared to long-leg casts.  Clinical experience also suggests that children with a short-leg cast may be able to walk sooner than many children treated with observation alone. However, the study first evaluated walking ability in the observation group only at 4 weeks and did not note when the children resumed walking.

The authors suggest a trend towards observation of toddler's fractures without follow-up imaging, similar to established benefits of removable splint or brace treatment for distal radius buckle fractures in children compared to short-arm casting.  However, observation is unlikely to catch on as widely for the distal tibia as splinting for the wrist for several reasons.  First, children who were observed had a higher likelihood of pain at follow-up intervals. This is also the clinical experience of many practitioners. Second, many parents express preference for some kind of protection for a fractured extremity of their very active toddlers. Finally, it may take longer for children to resume bearing weight with observation compared to casting, although this would require further study.

Further Research Needs

Research is needed to compare the outcomes of children with toddler's fractures treated in a short-leg walking cast versus observation.

References

[1] Fox J, Enriquez B, Bompadre V, Carlin K, Dales M. Observation Versus Cast Treatment of Toddler's Fractures. J Pediatr Orthop. 2022;42(5):e480-e485. doi:10.1097/BPO.0000000000002086

Any opinions expressed are solely those of the author and not of Cure 4 The Kids Foundation.