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Presumed toddler's fracture and above knee plaster

Three Part Question

In [toddler who is not weight bearing after a minor trauma whose xrays of tibia does not show a fracture] Should [above knee POP be applied] For [presumed toddler's fracture]

Clinical Scenario

12 months old boy tried to walk and fell over. He was unable to weight bear. Examination revealed mild tenderness over the distal tibia and xrays of tibia and fibula showed no fracture.
You wonder whether you should treat him in above knee plaster for presumed toddler's fracture.

Search Strategy

Cochrane database of systemic review and pubmed
Toddler's fracture AND distal tibial metaphysis fracture AND plaster

Search Outcome

103 papers found and 4 were relevant

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Matthew F.Halsey etal
59 children younger than 6 years who sustained a traumatic injury to the leg.RetrospectiveDetection of toddle's fracture in followup41% 16/39Small number Inclded 4 - 5 years
differentiating characteristics to diagnose toddler's fractureNo particular characteristic was found to predict outcome
BP Sharavat, SN Harrop, TP Kane
21 children between 9 months and 3 years with the diagnosis of toddler's fracture.Retrospective studyMissed fracture6/21 28%Small number No statistical analysis
History and nature of trauma9/21 definite history of trauma, 10/21 trivial injury, 2/21 no history of injury
Initial diagnosis and treatment11/21 definite fracture, 4/41 possible fracture,6/21 soft tissue injury
Milton Tenenbein, Martin H. Reed, G. Brian Black
37 children with the diagnosis of toddler's fractureRetrospectiveDetection of fracture at follow-up5/37Small number No statistical analysis
physical findings suggesting a fracture24/37 had point tenderness, 2/37 swelling and increased localised temperature,11/37 no local finding
JS Dunbar etal
7 children (9 months to 3 years old) with the diagnosis of toddler's fractureRetrospectiveFracture detection at follow up4/7No statistical analysis
common clinical findingUnable to weight bear and localized tenderness


It appears that higher proportion(upto 41%) of patients with normal initial xrays may be subsequently shown to have a toddler's fractue. Most studies(3/4) used plaster immobilisation if initial xray was normal.The inability to bear weight proved to be the most sensitive for toddler's fracture, it is not at all specific. Localised Tenderness was 71% sensitive and 67% specific.

Clinical Bottom Line

In children with the clear history of trauma who are unable to weight bear, an above knee plaster shoulder should be applied.


  1. Matthew F. Halsey Toddler's Fracture: Presumptive Diagnosis and Treatment Lippincott Williams & Wilkins 2001, 152-156
  2. BP Shravat Toddler's fracture J Accid Emerg Med 1996, 59-61
  3. Milton Tenenbein The Toddler's Fracture Revisited American Journal of Emergency Medicine 1990, 208-211
  4. J S Dunbar Obscure Tibial Fracture of Infants- The Toddler's Fracture Journal De L'association Canadienne Des Radiologistes September 1964, 136-144