Bauer Jennifer M, Lovejoy Steven A
Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.
Department of Orthopaedics, Monroe Carell Jr Children's Hospital at Vanderbilt Medical Center, Nashville, TN.
J Pediatr Orthop. 2019 Jul;39(6):314-317. doi: 10.1097/BPO.0000000000000948.
The toddler's fracture is a common pediatric nondisplaced spiral tibia fracture that is considered stable with a course of immobilization. However, there is no widely accepted type of immobilization, expected time to weight-bear, nor guidelines for radiographic monitoring. We aimed to compare immobilization type with respect to displacement and time to weight-bear, as well as determine the usefulness of follow-up radiographs.
A 3-year retrospective chart review of all children aged 9 months to 4 years who had a lower leg radiograph was performed. Those who fulfilled the criteria of a nondisplaced spiral tibia fracture, without fibula or physeal injury, were included in data collection, as were subjects with a negative initial radiograph that were treated presumptively as a toddler's fracture. Subjects were compared with regard to clinical and radiographic presentation; initial and subsequent immobilization; and clinical and radiographic follow-up.
There were 606 subjects with lower leg radiographs, with 192 meeting study criteria: 117 (61%) with an initially visible fracture and 75 (39%) without. Of the 75 without initially visible fractures, 70 (93%) had robust periosteal reaction on follow-up, and none were diagnosed as anything further. At final follow-up, 184 (96%) were known to be weight-bearing, with 98% of these by 4 weeks. There was an earlier return to weight-bear for those initially treated in a boot compared with short leg cast (2.5 vs. 2.8 wk, P=0.04), but there were no other differences between immobilization type. No fractures displaced at any time point, including 7 that had received no immobilization. Patients received an average of 2.5 two-radiograph series; no radiographs were noted to affect treatment decisions in follow-up.
In our cohort, initial immobilization of a toddler's fracture in a boot may allow faster return to weight-bearing, but fractures were universally stable regardless of immobilization type, and nearly all regained weight-bearing by 4 weeks. This reliable healing suggests that immobilization type can be at the physician and family's discretion, and that radiographic follow-up may be unnecessary for treatment planning.
Level III-this is a retrospective comparative study.
幼儿骨折是一种常见的小儿非移位性螺旋胫骨骨折，通过一段时间的固定被认为是稳定的。然而，目前尚无广泛接受的固定类型、预期负重时间以及影像学监测指南。我们旨在比较不同固定类型在骨折移位和负重时间方面的差异，并确定随访X线片的作用。
对所有9个月至4岁接受小腿X线检查的儿童进行了为期3年的回顾性病历审查。符合非移位性螺旋胫骨骨折标准且无腓骨或骨骺损伤的儿童被纳入数据收集，初始X线片阴性但被推定为幼儿骨折进行治疗的受试者也包括在内。对受试者的临床和影像学表现、初始及后续固定情况以及临床和影像学随访情况进行了比较。
共有606名接受小腿X线检查的受试者，其中192名符合研究标准：117名（61%）最初可见骨折，75名（39%）最初未见骨折。在75名最初未见骨折的受试者中，70名（93%）在随访时出现明显的骨膜反应，且均未被诊断为其他疾病。在最终随访时，184名（96%）已知已负重，其中98%在4周时已负重。与短腿石膏固定相比，最初采用靴子固定的患者恢复负重的时间更早（2.5周对2.8周，P=0.04），但不同固定类型之间没有其他差异。在任何时间点均无骨折移位，包括7名未接受固定的患者。患者平均接受了2.5次双X线片检查；在随访中未发现X线片影响治疗决策。
在我们的队列中，幼儿骨折最初采用靴子固定可能允许更快恢复负重，但无论固定类型如何，骨折普遍稳定，几乎所有患者在4周时都恢复了负重。这种可靠的愈合表明固定类型可由医生和家属自行决定，并且影像学随访对于治疗计划可能是不必要的。
III级——这是一项回顾性比较研究。
