Definitive Management
There are two important goals when treating children with ankle fractures—achieving a satisfactory reduction and avoiding physeal arrest so as to minimize the risks of angular deformity, early arthrosis, leg-length inequality, and joint stiffness.11 Juvenile Tillaux fractures with greater than 2 mm of displacement require orthopedic consultation for closed or open reduction. Closed reduction is attempted by internally rotating the foot and applying direct pressure over the anterolateral tibia. If necessary, percutaneous pins can be used for stabilization of the reduction. If closed reduction is unsuccessful, open reduction is required. Care must be taken to assure no displacement occurs after casting; this requires weekly X-ray evaluation for the first 2 weeks.12
Patients with nondisplaced Salter-Harris III fractures are treated with long-leg casting for 4 weeks with conversion to a short-leg cast or boot for an additional 4 weeks. Patients should anticipate 8 weeks of nonweight-bearing. The patient is allowed to remove the boot for range-of-motion exercises but must remain nonweight-bearing for the first 2 weeks.14
Case 4
A 3-year-old previously healthy girl presented to the ED with a limp and difficulty bearing weight. Her mother reported that the child was playing in the yard when she caught her foot on a tree root, stumbled, and fell down. Since the incident, the child has been tearful, limping, and refusing to walk.
Tibial Fractures
Tibial fractures are among the most frequent types of orthopedic injuries in young children, with only femur and forearm fractures having a higher incidence of occurrence. Tibial fractures account for up to 15% of long bone fractures in children and adolescents.16,17 The mechanism of injury varies depending on the patient’s age. In young children, the most common cause of injury is from a seemingly minor twisting around a fixed foot or from a minor fall. In older children and adults, high-energy motor vehicle accidents and sports-related injuries are more common causes.
Fractures of the tibial shaft are typically short oblique or transverse fractures of the middle or distal third of the shaft. Thirty percent of tibial shaft fractures are associated with fractures of the fibula.16
Toddler’s Fracture
The term toddler’s fracture refers to a nondisplaced oblique fracture of the tibial shaft without concomitant fibular fracture. It usually results from an indirect rotational or twisting force applied to the foot and lower leg.16-18 More specifically, the term describes a specialized case of spiral fracture of the distal tibia in patients aged 9 months to 3 years, when weight-bearing is just beginning.19,20 Such injuries commonly occur when a toddler stumbles and falls, or attempts to extricate the foot from between the bars of a crib. Often, however, the mechanism is minimal or unknown.18 Of those injuries that are witnessed, most caregivers report a minor twisting mechanism. Most children with toddler’s fracture are younger than age 6 years. Sixty-three of 76 such fractures reported by Dunbar et al17,19 occurred in children younger than 2.5 years of age. Toddler’s fractures occur more often in boys than girls, and in the right leg more often than the left. Most children will give a history of tripping or twisting their ankle.17
Evaluating the Toddler
Toddlers can be challenging patients as they can not relate history and are often uncooperative on examination. A child may present with a limp, diminished movement of the affected limb, or refuse to bear weight without a distinct history of injury. The onset of limping or refusal to bear weight after minor trauma, or without an obvious injury in a young ambulatory child, warrants a detailed examination looking for tenderness over the tibia, along with radiographic evaluation to rule out a toddler’s fracture.
The examination of the patient is rarely impressive as there is little swelling and bruising with most toddlers’ fractures. A complete clinical history is needed, including a detailed description of any observed traumatic event to exclude the existence of other injuries.
When no traumatic event is observed or an inconsistent history is provided, the physician should obtain a detailed social history, including a list of the child’s most recent caregivers and contacts.16 Because of mild clinical symptoms and frequent lack of a history of injury in this patient population, presentation for evaluation may be delayed. In such cases, by the time the extremity is examined, the fracture has begun to heal. This healing phase may be accompanied by periosteal new bone and, in the absence of a history, may erroneously suggest other, more ominous conditions such as osteomylelitis or tumor.17,18
Consideration of Abuse
Although tibial shaft fractures are rarely found in abused children, diagnosis of child abuse must be considered in cases where a tibial fracture is discovered in the nonambulatory child; his or her clinical history is inconsistent with the injury; and/or there are other physical findings suggestive of abuse. Investigation for suspected nonaccidental trauma includes a thorough physical examination, skeletal survey, and evaluation by social services personnel.16