[Toddler's Fractures: Definition, Differences between the Diagnostic and Therapeutic Approach]

PURPOSE OF THE STUDY The term toddler's fracture was first coined by J. S. Dunbar in 1964 as a nondisplaced fracture of the distal tibia in children aged 9 months to 3 years. Over time, many other authors extended this definition as to the location as well as age range. The purpose of this paper is to provide a comprehensive overview of the existing studies focusing on the topic of toddler's fractures, to compare individual diagnostic and therapeutic approaches, and to specify the term toddler's fracture. Also, a group of patients with this diagnosis is presented, treated at our department. MATERIAL AND METHODS A retrospective study of a group of patients treated at the Department of Paediatric and Trauma Surgery, 3rd Faculty of Medicine, Charles University in the period from 1. 1. 2012 to 2. 8. 2017. The defined age range of patients was 9 months up to 3 years. The most frequent type of skeletal injury at this age was identified. Also, the etiology of injuries, the method and duration of fixation were examined. Moreover, an overview of foreign articles, with a focus on diagnosis and therapeutic approach is presented. RESULTS In the respective five-year period, a total of 15,679 children with a skeletal injury were treated at the Department of Paediatric and Trauma Surgery, of whom 57 patients at the age of a toddler (9 months to 3 years of age) sustained a nondisplaced distal tibial metaphyseal fracture (0.4%). In addition, 147 patients were treated for nondisplaced fracture of the first metatarsal base (0.9%) - in 98 of whom it was a torus fracture, in 49 patients the fracture line extended into the physis; therefore, it concerned the Salter-Harris type II separation of epiphysis. The group included only one patient with a nondisplaced calcaneal fracture. DISCUSSION Despite differences in the definition as to the location and age of patients, the toddler's fractures can always be defined as nondisplaced, and in many cases, they are difficult to diagnose based on the initial X-rays. Crucial for a differential diagnosis is to distinguish them from osteomyelitis, synovitis of the hip joint, or a tumour. In case of unclear history, also the Child Abuse and Neglect syndrome shall be considered. When any of the aforementioned diagnoses is suspected, methods with a higher diagnostic yield (but in case of computed tomography and scintigraphy also with a higher burden) - ultrasound, CT or scintigraphy - can be used. CONCLUSIONS We recommend that the term "toddler's fracture" is used for nondisplaced fractures of the distal third of the tibia with respect to the original criteria proposed by Dunbar. We consider as an option to include in this group also the first metatarsal fractures due to their frequency in this age group, provided that the stated conditions are met. Key words: toddler's fracture, tibial fractures, toddlerhood, diagnosis, treatment.