| Fracture Type | Reduction | Immobilisation | Follow-up |
|---|
| Toddler fracture | Not required | Optional above-knee walking cast x 4 weeks or backslab | Fracture clinic in 2 weeks + XR |
| Undisplaced tibial shaft | Not required | Above-knee cast x 4–6 weeks (non-WB); procedural sedation helpful | Fracture clinic in 1 week + XR |
| Displaced ± fibular fracture | Required | Closed reduction → above-knee cast x 4–6 weeks (non-WB) | Fracture clinic in 1 week + XR |
| | GA + MUA or operative fixation if unstable | |
Classification
- Location: Proximal, middle, or distal third
- Pattern: Transverse, oblique/spiral, comminuted, open
- Associated Injury: Fibula fracture (30% of cases)
Epidemiology & Mechanism
- 3rd most common long bone fracture in paediatrics
- Mechanism:
- Direct blow → transverse or segmental fracture
- Rotational force → spiral/oblique fracture
Clinical Features
- Pain, swelling, leg deformity
- Inability to weight bear
Toddler Fracture
- Age: 9 months to 3 years (ambulatory toddlers)
- Type: Spiral/oblique undisplaced fracture of distal tibial shaft
- Intact fibula & periosteum
- Cause: Low-energy twisting injury
- Must exclude osteomyelitis and septic arthritis
Radiological Investigations
- X-ray: AP + lateral of tibia & fibula including knee and ankle
- Consider oblique views if fracture not visible
- Periosteal reaction may only appear after 7–10 days
X-ray Appearance
- Toddler fracture: Often occult on initial XR, periosteal reaction visible later
- Undisplaced shaft: Short oblique/transverse in mid-distal third
- Displaced shaft: Possible varus drift if fibula intact (cast in slight valgus)
- Tib + fib fracture: May be at different levels
Indications for Reduction
Any displaced fracture.
Post-reduction XR: must include knee and ankle.
Acceptable Alignment
| Parameter | <8 years | >8 years |
|---|
| AP/Lateral angulation | ≤10° | ≤5° |
| Shortening | ≤10 mm | ≤5 mm |
| Rotation | ≤10° | ≤5° |
| Apposition | 0% | ≥50% |
Indications for Orthopaedic Referral (Urgent)
- Open fracture
- Suspected compartment syndrome or severe swelling
- Neurovascular compromise
- Inability to reduce or maintain reduction
- Ipsilateral injuries
- Inexperienced ED team
ED Management by Fracture Type
| Fracture | Reduction | Immobilisation Details |
|---|
| Toddler fracture | Not required | Optional above-knee walking cast x 4 weeks; backslab also suitable |
| Undisplaced tibial shaft | Not required | Above-knee cast x 4–6 weeks (non-WB), knee flexed 30–40°, ankle in neutral DF |
| Displaced ± fibula shaft fracture | Closed reduction / GAMP | Above-knee cast x 4–6 weeks (non-WB), then convert to below-knee/PTB cast if needed |
Follow-up
- Undisplaced / Displaced fractures:
→ Fracture clinic in 1 week with repeat XR
- Toddler fractures:
→ Fracture clinic in 2 weeks with XR
Parental Advice
- Most fractures heal uneventfully in 8–12 weeks
- Provide cast care education (“Caring for your child in a leg cast” sheet)
- Reinforce need for follow-up to monitor alignment
Potential Complications
- Compartment syndrome: Increasing pain, pain on passive stretch, late vascular signs
- Vascular injury: Rare but serious—especially with proximal tibial fractures
- Angular deformity (varus): Especially if fibula intact—requires close early follow-up
- Others: malunion, nonunion (rare in children)
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