Toddler fractures, also known as childhood accidental spiral tibial (CAST) fractures, are minimally displaced or undisplaced spiral fractures, usually of the distal tibia, commonly encountered in toddlers. It is potentially difficult to diagnose because the symptoms and imaging findings can both be subtle 10.
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Terminology
The term toddler fracture has sometimes also been used to describe occult fractures of other lower limb bones in the same age group (e.g. fibula, cuboid, calcaneum 1,3). Childhood accidental spiral tibial (CAST) fracture is a term proposed to encompass a broader age range of up to 8 years 11.
It is important to note that toddler fractures do not include spiral femoral fractures, which should raise suspicion of non-accidental injury (NAI) 4.
Epidemiology
Toddler fractures typically occur between the ages of 9 months and 3 years 1,2, although they can occur up to the age of 8 years 1. The incidence has been reported at ~1.5 (range 1-2.5) per 1000 children/year 11.
Although early (c.2006) reports 5 suggested that tibial toddler fractures were indicative of NAI, subsequent work has suggested that this is not the case and that the vast majority are not suspicious 4. Features that have been associated with tibial fractures and NAI include unclear mechanism, <18 months old, non-ambulatory infants, unmarried/single parent 11.
Clinical presentation
Children typically have vague symptoms not clearly related to the tibia presenting with non-specific pain, inability to weight-bear, and localized tenderness 11. There may not be a history of injury 11.
Pathology
Toddler fractures are due forced internal rotation of the proximal leg while the foot and ankle are fixed (e.g. trip while walking/running, jump from height), with the resultant torsional force fracturing the tibia in a spiral pattern 11.
Radiographic features
Conventional radiographs are all that are required; however, multiple views (AP and lateral) are necessary as the fracture is often inapparent on one or more views 2, 11, and may occasionally be occult 10. Follow-up radiographs usually demonstrate slight sclerosis and periosteal reaction 2.
Plain radiograph
A non-displaced spiral or oblique fracture will be noted in the middle or distal diaphysis of the tibia 9,11. Internal oblique projection can better demonstrate the fracture in some cases 8,11.
Treatment and prognosis
If there is a mismatch between clinical presentation and plain radiograph findings (i.e. no fracture seen), follow-up x-rays after 2 weeks can help diagnose a toddler fracture 10,11.
Toddler fractures usually spontaneously heal with management varying between immobolisation (with cast, backslab, or CAM boot) verses no immobilization 11.
History and etymology
The Canadian radiologist, John Dunbar (1921-1997) first described toddler fractures in 1964 2.
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