Retrospective chart review of minor tibial fractures in preschoolers: immobilisation and complications

Emerg Med J. 2020 Jun;37(6):345-350. doi: 10.1136/emermed-2019-208930. Epub 2020 Apr 3.

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.

Keywords: immobilisation; skin breakdown; spiral fracture; tibial fracture; toddler’s fracture.

MeSH terms

  • Child, Preschool
  • Female
  • Humans
  • Immobilization / methods
  • Immobilization / standards*
  • Immobilization / statistics & numerical data
  • Infant
  • Male
  • Radiography / methods
  • Radiography / statistics & numerical data*
  • Retrospective Studies
  • Tibial Fractures / complications*
  • Tibial Fractures / therapy