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A 2-year and 11-month old child fell while playing with friends 2 hours ago and has avoided bearing weight on the right leg since that time. The child is afebrile and exam reveals tenderness along the distal tibial shaft with no significant swelling. Radiographs are shown in Figure A and B. What is the most appropriate treatment?
MRI of the tibia
Aspiration of the tibia
Referral to child services
Long leg cast application
Serum vitamin D, calcium, and phosphate levels
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The clinical presentation and radiographs are consistent with a toddler's fracture of the tibia and the next step in management includes long leg cast application.
Mellick et al provide a review of tibial fractures in hospitalized children and describe their associations with non accidental trauma. This fracture often times presents as a gait disturbance in a young child. In this scenario, a witnessed fall in ambulatory child with avoidance of weight bearing after falling is consistent with a toddlers fracture. They provide additional recommendations regarding nonmenclature clarity for isolated spiral fractures of the tibia.
Mashru et al reviewed the treatment of tibial shaft fractures in children and adolescents. The recommendations for toddler fractures include long leg casting for only 4 weeks.
Answers 1 and 2. The radiographs demonstrate a non-displaced spiral fracture of the distal tibial shaft without signs/symptoms of infection, so MRI and aspiration are not appropriate.
Answer 3. Child abuse should be suspected with long bone fractures of the lower extremity in child who are not yet ambulatory, but in this child, this is not this case.
Answer 5. Metabolic work-up is not warranted for this common type of fracture with appropriate injury mechanism.
Mellick LB, Reesor K, Demers D, Reinker KA.
Pediatr Emerg Care. 1988 Jun;4(2):97-101. PMID: 3380753 (Link to Abstract)
Mashru RP, Herman MJ, Pizzutillo PD
J Am Acad Orthop Surg. 2005 Sep;13(5):345-52. PMID: 16148360 (Link to Abstract)
Mashru, JAAOS 2005
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A 23-month-old girl refuses to bear weight since falling on the playground yesterday. The child is afebrile and her WBC and erythrocyte sedimentation rate (ESR) are within normal limits. On physical exam the leg has no erythema, but does have mild tenderness along the distal tibial shaft. Plain radiographs are negative. What is the most appropriate management?
vitamin D and calcium levels
MRI of the pelvis
long leg cast
aspiration of the knee
The clinical presentation is consistent with a toddler's fracture, which is treated with a long leg cast. Initial radiographs are often negative but follow-up radiographs may demonstrate a healing periosteal reaction.
According to Mashru et al in a review of tibia fractures, toddler's fractures are one of the most common injuries in the child younger than 2 years. They are non-displaced spiral fractures of the tibia caused by low-energy twists and falls. The treatment is application of a long leg cast for 3-4 weeks.
Average 3.0 of 26 Ratings
HPI - 13 year-old male experienced trauma two weeks ago and suffered both bone fracture. The patient was initially treated in a long let cast.
Based on the 2 week xrays, how would you treat this pediatric tib-fib fracture?
HPI - struck by car
no soft tissues problem, no other injuries,
What is the best treatment option?
HPI - 12 year old female softball player got her cleats stuck sliding into home plate and twisted her lower leg.
Treatment for this adolescent tibial shaft fracture