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Toddler’s Fractures

Time to Weight-bear With Regard to Immobilization Type and Radiographic Monitoring

Bauer, Jennifer M., MD, MS*; Lovejoy, Steven A., MD

Journal of Pediatric Orthopaedics: July 2019 - Volume 39 - Issue 6 - p 314–317
doi: 10.1097/BPO.0000000000000948
Trauma Lower Extremity

Background: The toddler’s fracture is a common pediatric nondisplaced spiral tibia fracture that is considered stable with a course of immobilization. However, there is no widely accepted type of immobilization, expected time to weight-bear, nor guidelines for radiographic monitoring. We aimed to compare immobilization type with respect to displacement and time to weight-bear, as well as determine the usefulness of follow-up radiographs.

Methods: A 3-year retrospective chart review of all children aged 9 months to 4 years who had a lower leg radiograph was performed. Those who fulfilled the criteria of a nondisplaced spiral tibia fracture, without fibula or physeal injury, were included in data collection, as were subjects with a negative initial radiograph that were treated presumptively as a toddler’s fracture. Subjects were compared with regard to clinical and radiographic presentation; initial and subsequent immobilization; and clinical and radiographic follow-up.

Results: There were 606 subjects with lower leg radiographs, with 192 meeting study criteria: 117 (61%) with an initially visible fracture and 75 (39%) without. Of the 75 without initially visible fractures, 70 (93%) had robust periosteal reaction on follow-up, and none were diagnosed as anything further. At final follow-up, 184 (96%) were known to be weight-bearing, with 98% of these by 4 weeks. There was an earlier return to weight-bear for those initially treated in a boot compared with short leg cast (2.5 vs. 2.8 wk, P=0.04), but there were no other differences between immobilization type. No fractures displaced at any time point, including 7 that had received no immobilization. Patients received an average of 2.5 two-radiograph series; no radiographs were noted to affect treatment decisions in follow-up.

Conclusions: In our cohort, initial immobilization of a toddler’s fracture in a boot may allow faster return to weight-bearing, but fractures were universally stable regardless of immobilization type, and nearly all regained weight-bearing by 4 weeks. This reliable healing suggests that immobilization type can be at the physician and family’s discretion, and that radiographic follow-up may be unnecessary for treatment planning.

Level of Evidence: Level III—this is a retrospective comparative study.

*Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE

Department of Orthopaedics, Monroe Carell Jr Children’s Hospital at Vanderbilt Medical Center, Nashville, TN

There were no sources of support or funding.

The authors declare no conflicts of interest.

Reprints: Jennifer M. Bauer, MD, MS, Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803. E-mail:

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