Management of Toddler's Fractures in the Pediatric Emergency Department

Objectives: To evaluate current practice in treatment of toddler's fractures, as well as subsequent healthcare utilization and complications. Methods: Retrospective cohort study of children age 9 months to 3 years with a radiographically evident toddler's fracture diagnosed at a single academic pediatric emergency department (PED) from January 2008 to December 2012. Data collected included initial form of immobilization (if any), referral to orthopedic clinic, number of repeat radiographs obtained, presence of skin breakdown related to splinting or casting, and presence of other complications. Results: Seventy-five patients were treated. Most patients were placed in splints or casts in the PED (66.7%) as opposed to controlled ankle motion (CAM) boot (24%) or no immobilization (9.3%). Splinted patients had a longer total duration of immobilization, higher rate of follow-up in orthopedic clinic, and greater number of repeat radiographs obtained than those in the CAM boot or no immobilization groups. Thirteen patients (17.3%) developed skin breakdown during their course of therapy; all of these patients had been placed in a splint or cast in the PED. No difference in PED return rates was observed between groups. Conclusions: There is wide variation in management of toddler's fractures within this single tertiary care PED. Given that these fractures are unlikely to displace and that complications of splinting and casting are not insignificant, this study suggests that immobilization may not be necessary for acute management of toddler's fractures.