Toddler’s Fracture

Toddler’s fracture is a common, yet often under-recognized injury in young children, typically between the ages of 9 months and 3 years. It refers to a non-displaced spiral fracture of the distal tibia, the larger of the two bones in the lower leg. These fractures generally occur from low-impact trauma, such as a simple fall while running or jumping. Due to the subtle nature of this fracture, it can sometimes go unnoticed on initial X-rays, making careful clinical evaluation essential. Early diagnosis and management are important to ensure proper healing and to avoid complications (1).

Symptoms

The hallmark symptom of a toddler’s fracture is sudden refusal to bear weight on the affected leg, often following a minor trauma. Additional signs and symptoms may include (1):

• Limping or refusal to walk
• Mild to moderate swelling of the lower leg
• Tenderness over the distal tibia
• Pain upon movement or when standing
• Crying or irritability, especially when the leg is touched or moved
• No visible deformity or bruising in most cases

It’s important to note that toddlers often cannot verbalize their discomfort, so a sudden change in walking behavior or mood should prompt further evaluation (1).

Causes

Toddler’s fractures typically occur due to a twisting injury to the leg, often during a seemingly harmless fall or awkward step. Common causes include (2):

• Tripping while learning to walk or run
• Jumping from low heights, such as furniture
• Slipping while playing
• Sudden pivoting or missteps

Unlike high-energy trauma seen in older children or adults, toddlers’ fractures are usually the result of low-impact mechanisms due to the unique biomechanical properties of young children’s bones (2).

Risk Factors

Several factors can increase the likelihood of a toddler sustaining this type of fracture (1):

• Age: Most cases occur in children aged 1 to 3 years, when walking and running abilities are still developing.
• Recent initiation of walking: Newly walking toddlers are more prone to falls.
• Unsupervised play: Playing in areas with uneven surfaces or hard flooring can increase fall risk.
• Bone physiology: The bones in toddlers are softer and more flexible, making them susceptible to spiral-type fractures from twisting forces.
• Previous injuries: A child with a history of falls or bone fragility may be more vulnerable.

Diagnosis

Diagnosing a toddler’s fracture can be challenging due to the nonspecific nature of the symptoms and the subtle radiographic findings. Diagnosis typically involves a combination of clinical assessment and imaging studies (3):

• Physical Examination: A pediatrician or orthopedic specialist will look for localized tenderness over the tibia, reluctance to bear weight, and signs of swelling.
• X-rays: Anteroposterior (AP) and lateral views of the tibia are usually taken. However, early X-rays may appear normal if the fracture is non-displaced. Oblique views may improve detection.
• Follow-Up Imaging: If initial imaging is inconclusive but clinical suspicion remains high, a follow-up X-ray after 7 to 10 days may reveal periosteal new bone formation or a clearer fracture line.
• Other Imaging: In rare cases, an MRI or bone scan may be used to confirm the diagnosis if symptoms persist without radiographic evidence (3).

Treatment Options

Most toddlers’ fractures are managed conservatively due to their non-displaced nature and the excellent healing capacity in children. Treatment goals include pain relief, immobilization, and promoting natural healing (1).

Common treatment methods include:

• Immobilization: A long leg cast or short leg walking boot is typically applied to stabilize the fracture for 3–4 weeks. Immobilization reduces pain and prevents further injury.
• Pain Management: Over-the-counter analgesics like acetaminophen or ibuprofen may be prescribed for discomfort.
• Limited Weight-Bearing: Initially, children are advised to avoid bearing weight on the affected leg. As healing progresses, gradual return to walking is allowed.
• Follow-Up: Periodic check-ups with repeat X-rays may be recommended to monitor healing and ensure proper alignment.

Surgical intervention is rarely required unless complications arise, such as fracture displacement or suspicion of non-accidental trauma (2).

Living With or Prevention

Living With a Toddler’s Fracture

Children with toddler fractures usually recover fully within 4 to 6 weeks, often regaining full function without long-term complications. Parents and caregivers can help ensure a smooth recovery by (4):

• Ensuring the cast remains dry and intact
• Preventing high-impact activities during the healing phase
• Encouraging gentle movement once permitted
• Monitoring for signs of complications such as fever, increased pain, or cast issues

Most toddlers quickly resume normal activity levels following treatment, and recurrence is rare (4).

Prevention Tips

While it’s not always possible to prevent toddlers’ fractures, especially during the early walking stages, some precautions can minimize the risk:

• Provide a safe, padded environment for play
• Avoid slippery surfaces where a child may fall
• Supervise toddlers closely, especially on stairs or elevated furniture
• Use safety gates and childproof areas where falling is likely
• Ensure the child wears supportive footwear to improve balance

Since toddlers are naturally prone to falls as they develop mobility, awareness, and supervision remain the best preventive strategies.

Toddler’s fractures may appear mild but require careful assessment and appropriate care to ensure complete healing. With timely treatment and parental awareness, children affected by this injury typically recover quickly and return to normal activities without lasting effects (4).

References

1. Alqarni N, Goldman RD. Management of toddler’s fractures. Can Fam Physician. 2018 Oct;64(10):740-741. PMID: 30315017; PMCID: PMC6184974.
2. Wang Y, Doyle M, Smit K, Varshney T, Carsen S. The Toddler’s Fracture. Pediatr Emerg Care. 2022 Jan 1;38(1):36-39. doi: 10.1097/PEC.0000000000002600. PMID: 34986580.
3. Schuh AM, Whitlock KB, Klein EJ. Management of Toddler’s Fractures in the Pediatric Emergency Department. Pediatr Emerg Care. 2016 Jul;32(7):452-4. doi: 10.1097/PEC.0000000000000497. PMID: 26087443; PMCID: PMC4449267.
4. Coveney J, Barrett M. Toddler fractures immobilisation and complications: A retrospective review. Injury. 2024 Jun;55(6):111566. doi: 10.1016/j.injury.2024.111566. Epub 2024 Apr 12. PMID: 38678675.