Initially described in 1964, a Toddler's Fracture (TF) is classically an isolated, nondisplaced, distal-third diaphyseal tibial spiral fracture in younger children [1]. The typical presentation is inability to weight-bear and the typical mechanisms of injury include low or high impact falls and trauma descending a slide [2,3]. Clinical findings include point tenderness, and painful ankle dorsiflexion [1]. In between 15 and 65% of cases [3], [4], [5], [6] initial plain film radiographs are normal and therefore in many case a presumptive clinical diagnoses is made. Retrospective reviews have found evidence of healing feature on repeat plain film in 45-95% of those with a presumptive diagnosis [3,7]. The fractures are stable with three large retrospective studies reporting 443 cases of TF with no case of displacement, malunion or non-union [3,8,9].

Historically treatment was, similar to adult tibial fractures, immobilisation in a non-weight bearing above-knee plaster of Paris for 6–8 weeks [1]. The current literature describes a full spectrum of approaches to management of TF [3,4,[9], [10], [11]]. They include: Immobilisation with full above knee casting, below knee casting, splinting, controlled ankle motion boots and no immobilisation. The differences in treatment approach between clinicians is highlighted by a survey of 153 Canadian paediatric emergency medicine (EM) physicians which found that for presumptive diagnosis of TFs, 44% would choose to manage without immobilisation and for a radiologically diagnosed TF 5% would choose to manage without immobilisation [12].

With regards to those managed without immobilisation there is limited published data available. A recent review found only six single-centre studies (199 children not-immobilised) which report on children with TF been treated without immobilisation [11]. Five were retrospective studies. The largest of these studies [10] (136 non-immobilised children) included both those with radiologically conformed TF and suspected TF (with normal X-rays), finding reduced ED representations in those not immobilised compared with those immobilised. A single prospective study [13] compared immobilisation with cast with no-immobilisation in 44 children with radiologically confirmed TF. 30 of the enrolled patients were not immobilised. The small sample size limits significant comparison between groups outcomes, however no significant poorer outcomes were noted in those not-immobilised.

This study aims to identify children with either a radiological or clinical diagnosis of toddler's fracture, describing initial management with comparison between cohorts managed with or without immobilisation.