Understanding Toddlers Fracture, Tibial and Fibular Stress Fractures: Epidemiology, Anatomy, Mechanism of Injury, Clinical Evaluation, Radiographic Evaluation, Treatment, and Complications

This article provides comprehensive information on toddler's fracture, tibial and fibular stress fractures, including epidemiology, anatomy, mechanism of injury, clinical and radiographic evaluation, treatment, and complications. Learn how to prevent stress fractures with proper conditioning, appropriate footwear, and training techniques.

Epidemiology

A toddler’s fracture is by definition a spiral fracture of the tibia in the appropriate age group.

• Most of these fractures occur in children younger than 2.5 years.
• The average age of incidence is 27 months.
• This tends to occur in boys more often than in girls and in the right leg more frequently than the left.

Most tibial stress fractures occur in the proximal third.

• The peak incidence of tibial stress fractures in children is between the ages of 10 and 15 years.
• The tibia is more often affected than the fibula in children; the opposite is true in adults.

Most fibular stress fractures occur in the distal third, but may also occur in the proximal third.

• The peak incidence of fibular stress fractures in children is between the ages of 2 and 8 years.

Anatomy

The distal epiphysis appears at approximately 2 years of age; thus, physeal injuries of the distal tibia may not be readily apparent and must be suspected.

Mechanism of Injury

The classic description of the mechanism of a toddler’s fracture is external rotation of the foot with the knee in fixed position, producing a spiral fracture of the tibia with or without concomitant fibular fracture.

• This injury has also been reported as a result of a fall.

An acute fracture occurs when the force applied to a bone exceeds the bone’s capacity to withstand it. A stress fracture occurs when a bone is subjected to repeated trauma with a strain that is less than what would have produced an acute fracture.

• With microtrauma, osteoclastic tunnel formation increases to remodel microcracks. New bone formation results in the production of immature, woven bone that lacks the strength of the mature bone it replaced, predisposing the area to fracture with continued trauma.
• Distal fibula stress fractures have been referred to as the “ice skater’s fracture,” because of the repeated skating motion that results in a characteristic fibular fracture approximately 4 cm proximal to the lateral malleolus.

Clinical Evaluation

Patients typically present irritable and nonambulatory or with an acute antalgic limp.

• The examination of a child refusing to ambulate without readily identifiable causes should include a careful history, with attention to temporal progression of symptoms and signs (e.g., fever), as well as a systematic evaluation of the hip, thigh, knee, leg, ankle, and foot, with attention to points of tenderness, swelling, or ecchymosis. This should be followed by radiographic evaluation as well as appropriate laboratory analysis if the diagnosis remains in doubt.
• In the case of a toddler’s fracture, pain and swelling are variable on palpation of the tibia. These features are usually appreciated over the anteromedial aspect of the tibia, where its subcutaneous nature allows for minimal soft tissue protection.

Patients typically present with an antalgic gait that is relieved by rest, although younger patients may refuse to ambulate.

• The pain is usually described as insidious in onset, worse with activity, and improved at night.
• Swelling is generally not present, although the patient may complain of a vague ache over the site of fracture with tenderness to palpation.
• Knee and ankle range of motion are usually full and painless.
• Occasionally, the patient’s symptoms and signs may be bilateral.

Muscle sprains, infection, and osteosarcoma must be excluded. Exercise-induced compartment syndrome overlying the tibia may have a similar clinical presentation.

Radiographic Evaluation

AP and lateral views of the leg should be obtained.

• An internal oblique radiograph of the leg may be helpful for demonstration of a nondisplaced spiral fracture as these fractures may be quite difficult to appreciate on plain films.
• Occasionally, an incomplete fracture may not be appreciated on presentation radiographs but may become radiographically evident 7 to 10 days after the injury as periosteal new bone formation occurs.
• Technetium bone scans may aid in the diagnosis of toddler’s fracture by visualization of diffusely increased uptake throughout the tibia. This may be differentiated from infection, which tends to produce a localized area of increased uptake.

AP and lateral views of the leg should be obtained to rule out acute fracture or other injuries, although stress fractures are typically not evident on standard radiographs for 10 to 14 days after initial onset of symptoms.

• Radiographic evidence of fracture repair may be visualized as periosteal new bone formation, endosteal radiodensity, or the presence of “eggshell” callus at the site of fracture.
• Technetium bone scan reveals a localized area of increased tracer uptake at the site of fracture and may be performed within 1 to 2 days of injury.
• Computed tomography rarely demonstrates the fracture line, although it may delineate increased marrow density and endosteal/periosteal new bone formation and soft tissue edema.
• Magnetic resonance imaging may demonstrate a localized band of very low signal intensity continuous with the cortex.

Treatment

A long leg cast for 2 to 3 weeks followed by conversion to a short leg walking cast for an additional 2 to 3 weeks is usually sufficient.

• Manipulation is generally not necessary because angulation and displacement are usually minimal and within acceptable limits.

The treatment of a child presenting with a tibial or fibular stress fracture begins with activity modification.

• The child may be placed in a long leg (tibia) or short leg (fibula) cast, initially non–weight bearing with a gradual increase in activity level. The cast should be maintained for 4 to 6 weeks until the fracture site is nontender and radiographic evidence of healing occurs.
• Nonunion may be addressed with open excision of the nonunion site with iliac crest bone grafting or electrical stimulation.

Complications

• Complications of toddler’s fractures are rare owing to the low-energy nature of the injury, the age of the patient, and the rapid and complete healing that typically accompanies this fracture pattern.
• Rotational deformity: Toddler’s fractures may result in clinically insignificant rotational deformity of the tibia as the fracture slides minimally along the spiral configuration. This is usually unnoticed by the patient but may be appreciated on comparison examination of the lower limbs.
• Recurrent stress fractures: These may be the result of overzealous training regimens, such as for gymnastics or ice skating. Activity modification must be emphasized to prevent recurrence.
• Nonunion: This is rare, occurring most commonly in the middle third of the tibia. Surgical intervention may be necessary with bone grafting or electrical stimulation.

toddlers fracture

tibial stress fracture

fibular stress fracture

epidemiology

anatomy

mechanism of injury

clinical evaluation

radiographic evaluation

treatment

complications

prevention

conditioning

proper footwear

training techniques.