Is immobilisation required for toddler’s fracture of the tibia?

Dear Editor

I read with interest the excellent article by Townley et al. (1) summarising the current evidence regarding toddler’s fracture management. While studies to delineate best treatment would be welcome there are a number of issues, some of which the authors describe, to consider when contemplating such work.

Diagnosis
1. The history has to delineate that a) injury occurred or b) onset of symptoms occurred suddenly and during activity, especially important if events were not witnessed. Failure to differentiate traumatic from non-traumatic causes of limp can result in failure to make the correct diagnosis.
2. Clinical examination can be challenging (2). Though observation of joint movements is important, direct inspection of the leg is not revealing. Examination should be patient and meticulous; often a subtle wince, or brief cessation of crying, on palpation of the anterior tibia or axial ankle loading is all that points to the diagnosis. Failure to perform a detailed examination may lead to imaging of the wrong area or omission of radiographs altogether.
3. Radiographs of the tibia and fibula are investigations of choice, but can initially be normal even in children with diagnostic clinical features (3). When I first started practicing it was standard to repeat radiographs at about 2 weeks to look for periosteal reaction as a sign of a previously occult fracture. However this finding was not consistent, even in those with persistent and well established clinical signs, suggesting that some children with a toddler’s fracture don’t develop any radiological features, though may still have a similar clinical course (3).
4. MRI imaging would be interesting but would require sedation or anaesthesia, and would not change management. Ultrasound (4) has been advocated for use in clinically suspicious but x-ray negative individuals but may be uncomfortable not to mention difficult to perform.

The above points highlight that the gold standard for toddler’s fracture diagnosis needs careful consideration in any future study design to ensure the correct patients are enrolled.

Treatment
As the authors state, clinical outcomes of toddler’s fractures are universally good whatever treatment is employed, or none. However, I would like to share the following observations.

1. Though immobilisation may not be needed to expedite and ensure healing, it is sometimes an important method of analgesia, especially in the early stages.
2. Involving parents in decision making is key; clearly explaining the diagnosis, prognosis and outcomes. Some parents, in my experience particularly with smaller children, are happy to carry or push the child more than normal, allow them to crawl, and administer analgesia if required. Others may request immobilisation for reasons that are not immediately obvious. I have found parental concern about ability to safely carry a child, for example due to physical disability or already having a smaller child, and particularly if they are a single parent, is a strong influence on decision making.

I agree with the authors’ interpretation of the current literature and consider that there is a propensity for over treatment. Intuitively, immobilisation, if needed, should be below knee and removable, such as a boot or bi-valved cast (if removable boots unavailable) to permit bathing and skin care. Analgesic effect and parental acceptability are important considerations for future research and qualitative work to better describe the latter may prove a beneficial endeavour before starting.

References
1. Townley S, Messahel S, Korownyk, Morely E, Perry DC. Is immobilisation required for toddler’s fracture of the tibia? BMJ 2022;379:e071764. doi: 10.1136/bmj-2022-071764 pmid: 36523187.
2. Alqarni N, Goldman RD. Management of toddler’s fractures. Can Fam Physician 2018;64:-1. pmid: 30315017.
3. Sapru K, Cooper Sapru K, Cooper JG. Management of the toddler’s fracture with and without initial radiological evidence. Eur J Emerg Med 2014;21(6):451-4. doi: 10.1097/MEJ.0000000000000144 pmid: 24802106.
4. Lewis D, Logan P. Sonographic diagnosis of toddler’s fracture in the emergency department. J Clin Ultrasound 2006;34(4):190-4. doi: 10.1002/jcu.20192 pmid: 16615049.