Management of an undisplaced distal tibial fracture in children (a 'toddler's fracture') : a systematic review with meta-analysis.

Abstract

An undisplaced distal tibial fracture, usually seen in young children and typically from a minor injury, is often called a 'toddler's fracture'. These fractures generally heal quickly with minimal complications. Immobilization may be associated with complications and delayed return to normal activities. The aim of this review was to compare fracture- and non-fracture-related outcomes between two groups of children: those treated with immobilization and those treated without immobilization. Outcomes included time to weightbear (TTWB), pain and discomfort, adverse events, the use of resources, and satisfaction. The review was conducted in accordance with PRISMA and registered on PROSPERO (CRD42023461206). Searches were conducted on MEDLINE, Web of Science, and Embase from inception to May 2024 with additional studies from screening references, grey literature, conference proceedings, preprint repositories, and web searches. We identified ten studies (eight retrospective cohorts and two randomized controlled trials) including 963 children (722 immobilized vs 241 nonimmobilized). There was no difference in TTWB in three studies, whereas two reported shorter TTWB in nonimmobilized compared with immobilized groups. The absence of standardized parameters made meta-analysis inappropriate. With regard to fracture-related adverse outcomes, there was no significant difference in risk (0.00 (95% CI -0.01 to 0.02)) between the groups. However, 14.7% (106 of 722) of those who were immobilized had immobilization-related adverse events. There were no significant differences in pain and discomfort between the groups (odds ratio 0.49 (95% CI 0.19 to 1.23)). All the studies had a serious risk of bias. Due to heterogeneity and a lack of standardized datapoints in the studies, the evidence remains inconclusive for TTWB and other outcomes in these children. Immobilization did not reduce fracture-related adverse events, pain, or discomfort but was, unsurprisingly, associated with an increased risk of immobilization-related adverse events. Conservative management without immobilization seems to be a satisfactory form of treatment of toddler's fractures, although high-quality studies are needed to explore key clinical and patient-related outcomes.