ICE 012: 2 year old with a painful leg

A 2 year old child is brought in by her mother. The child is limping and seemingly refusing to weight bear on the right leg. The mother is a little vague about what might have happened but wonders if her daughter was injured while playing with her older siblings out in the garden this afternoon. The child objects to you touching and moving her right lower leg.


  • Describe the abnormalities shown in her X-ray
  • How should this problem be managed?
  • Should you be concerned that the mother is unable to clearly explain the mechanism of injury?
Reveal the ICE answer

The x-ray demonstrates what is known as a “toddler fracture”. This is a spiral type fracture of the tibial shaft (in this case visible in both the AP and oblique in the mid to upper third of the tibia). Sometimes the fracture may even be less obvious than this with only a minor cortical irregularity while at other times the spiral nature of the fracture is obvious. On occasions though the fracture is suspected clinically it is only possible to diagnose it on a delayed (at 10 days) X-ray showing callus formation or on other imaging such as a bone scan.

The usual management is immobilisation in a long (above knee) cast for about 3 weeks. Whether this is always necessary or whether the outcome is similar without a cast or with a backslabsplint is currently debated.

Toddler fracture is caused by a rotational shearing force in a newly walking child. The initial injury is often not witnessed. The lack of a clear history always raises suspicion of non accidental injury but toddler fractures are generally considered to be unlikely to be associated with child abuse and are not suspicious.


ICE -Ian’s clinical emergencies 700


Ian’s clinical emergencies

emergency physician keen on medical education and cycling

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