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Coveney J, Barrett M. Toddler fractures immobilisation and complications: A retrospective review. Injury 2024; 55:111566. [PMID: 38678675 DOI: 10.1016/j.injury.2024.111566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/10/2024] [Accepted: 04/10/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND A Toddler's Fracture (TF) is classically an isolated, nondisplaced, distal-third diaphyseal tibial spiral fracture in younger children. A TF is stable and has a low risk of complication. There is lack of uniformity as to the optimal treatment for TF. Immobilisation with full above knee casting, below knee casting, splinting, controlled ankle motion boots and no immobilisation are all strategies currently in use. There is limited data from European centres regarding those treated without immobilisation. METHODS A retrospective review of electronic medical and radiology records was performed to identify all children presenting to a multisite department of paediatric emergency medicine in Ireland from January to December 2022. Those with radiologically confirmed TF or a presumptive diagnosis of TF were included. Data retrieved for each child included initial treatment and the number of and reason for ED reattendances relating to the injury in the 6-month period following the injury. RESULTS 166 children were identified, 96 with radiologically confirmed TF and 70 with presumptive diagnosis TF. Girls accounted for 47 % of presentations. Fall from a standing height (33 %) was the most common mechanism. 13 % (22/166) children were managed without immobilisation. Those with radiologically confirmed fracture (91/96) were significantly more likely to be immobilised than those with a presumptive diagnosis (53/70) (p = 0.001). In total 28 patients (17 % of total) represented to the ED within 6 months. The representation rate in those immobilised was 17 %, while in those not immobilised was 13 % (p = 0.66). CONCLUSION In this cohort, those with no radiological evidence of fracture are more likely to be managed without immobilisation. There was no significant difference in PED representations between those immobilised and not immobilised.
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Affiliation(s)
- John Coveney
- Department of Paediatric Emergency Medicine, Childrens Health Ireland @ Crumlin, Dublin, Ireland.
| | - Michael Barrett
- Paediatric Emergency Research and Innovation (PERI), Department of Paediatric Emergency Medicine, Childrens Health Ireland, Dublin, Ireland; Women's and Children's Health, School of Medicine, University College Dublin, Dublin, Ireland.
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Chen SN, Holstine JB, Samora JB. Reducing Rigid Immobilization for Toddler's Fractures: A Quality Improvement Initiative. Pediatr Qual Saf 2024; 9:e722. [PMID: 38576892 PMCID: PMC10990314 DOI: 10.1097/pq9.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/29/2024] [Indexed: 04/06/2024] Open
Abstract
Background Toddler's fractures are one of the most common orthopedic injuries in young walking-age children. They are defined as nondisplaced spiral-type metaphyseal fractures involving only the tibia without any injury to the fibula and are inherently stable. We aimed to use quality improvement methodology to increase the proportion of patients with toddler's fractures treated without cast immobilization at a large tertiary referral pediatric orthopedic center from a baseline of 45.6%-75%. Methods Baseline data on patient volume and treatment regimens for toddler's fractures were collected starting in February 2019. Monthly data were collected from the electronic medical record and reviewed to determine treatment (cast versus noncast immobilization) and tracked using statistical process control charts (p-chart). After determining the root causes of treatment using immobilization, interventions tested and adopted included physician alignment of expectations for treatment, sharing unblinded compliance data with providers, updating patient education materials, and updating resident education and reference materials. Results After interventions were in place, the percentage of patients treated without CAST immobilization increased from 45.6% to 90% (P ≤ 0.001). We also observed improvement in our process measure to increase the percentage of this population receiving boot immobilization during new patient visits in our orthopedic clinics (4.15% to 52%, P ≤ 0.001). Conclusions By aligning provider and family expectations for treatment, demonstrating no clinical need for cast immobilization, and bringing awareness of compliance to appropriate guidelines, our institution was able to improve care for patients with toddler's fractures and reduce financial and care burdens for families.
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Affiliation(s)
- Stephanie N. Chen
- From the Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis, Tenn
| | - Jessica B. Holstine
- Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, Ohio
| | - Julie Balch Samora
- Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Orthopaedic Surgery, Nationwide Children’s Hospital, Columbus Ohio
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Townley S, Messahel S, Korownyk C, Morely E, Perry DC. Is immobilisation required for toddler's fracture of the tibia? BMJ 2022; 379:e071764. [PMID: 36523187 DOI: 10.1136/bmj-2022-071764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- S Townley
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - S Messahel
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - C Korownyk
- Department of Family Medicine, University of Alberta, Canada
| | - E Morely
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - D C Perry
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK
- Faculty of Health and Life Sciences, University of Liverpool
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Boutin A, Misir A, Boutis K. Management of Toddler's Fracture: A Systematic Review With Meta-Analysis. Pediatr Emerg Care 2022; 38:49-57. [PMID: 34393216 DOI: 10.1097/pec.0000000000002488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In studies that included children diagnosed with toddler's fractures (TFs), we determined the fracture-related adverse outcomes in those treated with immobilization versus no immobilization. Furthermore, we compared health services utilization between these 2 immobilization strategies. METHODS A search was done on Ovid MEDLINE(R), Embase Classic + Embase, and Cochrane Central Register of Controlled Trials along with reference lists as conference proceedings and abstracts. No language or publication status or location restrictions were used. All study steps, including the methodological quality assessment, were conducted independently and in duplicate by 2 authors. RESULTS Of the 490 references identified, 4 retrospective studies of low quality met inclusion criteria and collectively included 355 study participants. With respect to fracture-related adverse outcomes, there was no risk difference [0; 95% confidence interval (CI), -0.09 to 0.09] between the immobilization and no immobilization treatment strategies. Furthermore, in the immobilization versus no immobilization groups, there was a higher mean difference in the number of radiographs (0.69; 95% CI, 0.15-1.23) and scheduled outpatient orthopedic visits (0.96; 95% CI, 0.24-1.68), but a decreased relative risk (0.41; 95% CI, 0.05-3.19) of repeat emergency department visits. No data were reported on patient pain or caregiver satisfaction. CONCLUSIONS In children with TF, this study suggests that no immobilization may be a safe alternative to immobilization for this minor fracture; however, high-quality evidence is needed to optimally inform clinical decision making. Future work should include validated measures of patient recovery, pain, and caregiver perspectives when comparing treatment strategies for this injury.
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Affiliation(s)
- Ariane Boutin
- From the Department of Pediatric Emergency Medicine, CHU Sainte-Justine and University of Montreal, Montreal
| | - Amita Misir
- Division of Emergency Medicine, Department of Pediatrics, London Health Sciences Center, London
| | - Kathy Boutis
- Division of Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Canada
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Abstract
OBJECTIVE The tibial toddler's fracture is an important diagnosis in both emergency and urgent care, presenting as acute onset lower extremity pain or limping in a young child. Diagnosis and management may be challenging because of an extensive differential diagnosis. The objectives of this study were to provide an overview of the toddler's fracture and to guide clinicians by summarizing up to date literature for both diagnosis and management this common condition. METHODS This study analyzed literature from the PubMed database from the years of 1964 to 2018. The main focus was on the diagnosis and management of the toddler's fracture. RESULTS This review demonstrates that diagnosis is primarily made through history and physical examination, as radiographs are often negative at initial presentation. Treatment involves a short period of immobilization, which can be facilitated through the use of a cast, a splint, or no external support. Successful healing and a full return to normal activities and development are near universal. CONCLUSIONS Although a stable fracture with an excellent prognosis, opportunities exist to improve toddler's fractures diagnosis and treatment protocols, to optimize clinical management.
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Affiliation(s)
- Yiqiao Wang
- From the University of Toronto Faculty of Medicine, Toronto
| | - Meagan Doyle
- Department of Pediatric Emergency Medicine, McMaster Children's Hospital, Hamilton
| | - Kevin Smit
- Division of Pediatric Orthopedics, Department of Surgery
| | - Terry Varshney
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Sasha Carsen
- Division of Pediatric Orthopedics, Department of Surgery
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Abstract
OBJECTIVES The aim of this study was to examine and compare the efficacy of external fixation strategies of toddler's fracture (TF) in acute care settings. Specifically, we aim to identify whether immobilization optimizes clinical outcomes for patients (based on immobilization duration, time to weight-bear/ambulate, and associated complications) compared with nonimmobilization, with a systematic review. STUDY DESIGN After PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, 2 independent reviewers searched electronic databases OVID Medline, Embase, and CINAHL for studies evaluating the health outcomes of various treatment methods for TF (1937-2019). The studies were chosen based on specific inclusion criteria. The 2 reviewers were looking for primary research articles that assessed health outcomes (such as immobilization duration, time to weight-bear/ambulate, and associated complications) of various treatment strategies for TF Fractures in acute care settings. RESULTS A total of 2385 articles were initially screened, reviewed, and then narrowed down to 6 studies for an in-depth analysis. Among these 6 studies, 5 were retrospective chart reviews and 1 was a cross-sectional online survey. A total of 565 patients from the retrospective chart reviews and 153 physicians from the cross-sectional online survey were further analyzed. The current evidence shows that there was no significant difference in clinical outcomes (ie, time to weight-bear and immobilization duration) between immobilization and nonimmobilization. CONCLUSIONS Further large-scale prospective studies examining the clinical outcomes of TF management techniques should be conducted to establish a consistent standardized guideline for TF treatment across acute care settings.
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Affiliation(s)
- Kristine Jeganathan
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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Murphy D, Raza M, Monsell F, Gelfer Y. Modern management of paediatric tibial shaft fractures: an evidence-based update. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:901-909. [PMID: 33978864 DOI: 10.1007/s00590-021-02988-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/21/2021] [Indexed: 11/30/2022]
Abstract
AIMS This review provides a summary of recent evidence surrounding the treatment of paediatric tibial shaft fractures and presents an algorithm to aid management of these injuries. This article reviews the relevant anatomy, epidemiology and aetiology of tibial shaft fractures and summarises contemporary treatment principles. Management recommendations and supporting evidence are given for fractures according to age (< 18 months, 18 months-5 years, 6-12 years, and 13-18 years). The relative merits of casting, plate fixation, elastic and rigid intramedullary nailing, and external fixation are discussed. Special attention is paid to the management of open tibial shaft fractures and to complications including infection and acute compartment syndrome. CONCLUSIONS There has been a shift away from non-operative management of paediatric tibial shaft fractures over the last 30 years. However, recent evidence highlights that a non-operative approach produces acceptable outcomes when used in simple closed fractures at any age. Operative management may be indicated for unstable fractures where satisfactory alignment cannot be maintained or in specific circumstances including open injuries and polytrauma. Open injuries require urgent assessment by a combined orthopaedic and plastic surgery team at a specialist tertiary centre.
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Affiliation(s)
- Daniel Murphy
- St George's University Hospitals NHS Foundation Trust, London, UK.
- St George's, University of London, London, UK.
| | - Mohsen Raza
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Yael Gelfer
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's, University of London, London, UK
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Wijtzes N, Jacob H, Knight K, Thust S, Hann G. Fifteen-minute consultation: The toddler's fracture. Arch Dis Child Educ Pract Ed 2021; 106:94-99. [PMID: 32817067 DOI: 10.1136/archdischild-2020-319758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/16/2020] [Accepted: 06/23/2020] [Indexed: 11/04/2022]
Abstract
The toddler's fracture is a distinct entity among tibial shaft fractures. It is defined as a minimally displaced or undisplaced spiral fracture, usually affecting the distal shaft of the tibia, with an intact fibula. They are often difficult to diagnose due to the absence of witnessed trauma and because initial radiographs may appear normal. Moreover, the presenting complaint (a non-weight bearing child) has a wide differential diagnosis. A detailed history and examination, together with additional imaging and other investigations, is crucial to diagnose a toddler's fracture. Analgesia and immobilisation are the mainstays of treatment, with follow-up in fracture clinic recommended. Inflicted injury (Note: this article will use the term inflicted injury which is also called non-accidental injury. In the field of safeguarding, there is a move away from using the term 'non-accidental injury' due to misinterpretation of the term as being less serious than 'abusive injury' and that in child protection reports the term can be easily misread or mistyped as 'accidental' injury) should always be considered when red flags for child abuse are present. In this article, we aim to cover the differential diagnoses for toddler's fracture including indicators that might suggest an inflicted injury.
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Affiliation(s)
- Nils Wijtzes
- Department of Paediatrics, North Middlesex University Hospital, London, UK
| | - Hannah Jacob
- Department of Paediatrics, North Middlesex University Hospital, London, UK
| | - Katie Knight
- Paediatric Emergency Medicine, North Middlesex University Hospital, London, UK
| | - Steffi Thust
- Radiology, University College London Hospitals NHS Foundation Trust, National Hospital for Neurology and Neurosurgery, London, UK
| | - Gayle Hann
- Department of Paediatrics, North Middlesex University Hospital, London, UK
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Llorente Pelayo S, Rodríguez Fernández J, Leonardo Cabello MT, Rubio Lorenzo M, García Alfaro MD, Arbona Jiménez C. Current diagnosis and management of toddler's fracture. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Ferrier CA, Schembri R, Hopper SM. Retrospective chart review of minor tibial fractures in preschoolers: immobilisation and complications. Emerg Med J 2020; 37:345-350. [PMID: 32245749 DOI: 10.1136/emermed-2019-208930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 02/08/2020] [Accepted: 02/22/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the treatment practices (immobilisation vs non-immobilisation) of toddler fractures and other minor tibial fractures (both proven and suspected) in preschoolers, aged 9 months-4 years, and examine rates of ED re-presentations and complications. METHODS Retrospective chart review of presentations of minor tibial fractures, both proven (radiologically confirmed) or suspected (negative X-ray but clinical evidence of bony injury), in children aged 9 months-4 years presenting to a single tertiary level paediatric ED from May 2016 to April 2018. Data collected included treatment practices, subsequent unscheduled re-presentations (including reasons) and complications (defined as problems relating to the injury that required further active care). RESULTS A search of medical records yielded 240 cases: 102 had proven fractures (spiral, buckle or Salter-Harris II) and 138 were diagnosed with a suspected fracture. 73.5% of proven fractures were immobilised, predominantly with backslabs. 79% of suspected fractures were treated with expectant observation without immobilisation. Patients treated with immobilisation were more likely to re-present to ED compared with non-immobilised patients (18/104, 17.3% vs 9/136, 6.6% RR 2.62, 95% CI 1.23 to 5.58). 21 complications were seen in 19/104 (18.3%) immobilised patients. There were eight skin complications (complication rate of 7.7%) and 11 cast issues (complication rate of 10.6%). Two (1.5%) of the 136 patients had complications related to pain or limp. Pain was uncommonly found, although follow-up was not universal. CONCLUSION In our centre, proven minor tibial fractures were more likely to receive a backslab, whereas for suspected fractures, expectant observation without immobilisation was performed. Although there is potential bias in the identification of complications with immobilisation, the study suggests that non-immobilisation approach should be investigated.
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Affiliation(s)
- Charlotte A Ferrier
- Melbourne Clinical School, The University of Notre Dame Australia Melbourne Clinical School, Werribee, Victoria, Australia
| | - Rachel Schembri
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Sandy M Hopper
- Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia .,Faculty of Medicine, Dentistry and Health Sciences, Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Abstract
Approximately one-third of children sustain a fracture before the age of 16 years; however, their unique anatomy and healing properties often result in a good outcome. This article focuses on the diagnosis and management of pediatric extremity injuries. The article describes the anatomic features and healing principles unique to children and discusses pediatric upper and lower extremity fractures and presents evidence-based and standard practice for their management. Finally, the article describes the conditions under which emergency physicians are likely to miss pediatric fractures by highlighting specific examples and discussing the general factors that lead to these errors.
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Llorente Pelayo S, Rodríguez Fernández J, Leonardo Cabello MT, Rubio Lorenzo M, García Alfaro MD, Arbona Jiménez C. [Current diagnosis and management of toddler's fracture]. An Pediatr (Barc) 2019; 92:262-267. [PMID: 31311775 DOI: 10.1016/j.anpedi.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/14/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Toddler's fracture is an accidental spiral tibial fracture, characteristic of the early childhood. The objective of this study is to determine the incidence and current diagnosis and management of this disorder. PATIENTS AND METHODS A retrospective study was conducted on a sample of patients aged 0-3 years diagnosed with a toddler's fracture in a tertiary hospital between years 2013 and 2017. RESULTS A total of 53 patients were registered (10.6 cases per year). The median age was 2 years, with a slight male predominance. The initial radiograph was normal in 24.5% of patients. With the initial approach, 69.8% of patients were diagnosed with fracture, 11.3% with suspected fracture, and 18.9% with contusion. A follow-up was required in 22% required a control test, using radiographs in 10 patients (pathological 90%), and ultrasound in 5 (pathological 80%, 3 of them with normal initial radiography). The large majority (80.8%) of the patients were immobilised with a cast, while flexible immobilisation or non-immobilisation was used in 19.2%. Complications were found in a 21.4% of patients immobilised with splint, mainly skin injuries (19%). These were more frequent in this group than in those that were not immobilised (21.4% vs. 0%, P=.006); with no significant differences in time to weight-bearing. CONCLUSIONS Radiography has a limited sensitivity for the diagnosis of toddler's fracture. In the group of patients with normal radiography, the use of ultrasound can be helpful to the diagnosis and avoid additional radiation. Even though the most common treatment continues to be immobilisation with a splint, the alternative without rigid immobilisation does not seem to give worse results, even with lower morbidity associated with the treatment.
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Affiliation(s)
| | - Juan Rodríguez Fernández
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | | | - Mónica Rubio Lorenzo
- Unidad de Ortopedia Infantil, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - M Dolores García Alfaro
- Unidad de Ortopedia Infantil, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Carmelo Arbona Jiménez
- Unidad de Ortopedia Infantil, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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