Definition
- Undisplaced spiral or oblique fracture of the distal tibial shaft with an intact fibula
- Occurs in newly walking children
Epidemiology
- Children 1 to 4 years
- Low energy twisting injury
- Accident often not witnessed
Clinical Features
- Acute limp or refusal to weight bear
- Child is otherwise well and afebrile
- Tenderness or warmth over the distal tibia, sometimes hard to localise
- Pain on gentle twisting of the leg
Investigations
- AP and lateral radiographs, add oblique views
- Fracture may be invisible initially
- Repeat radiographs at 10 to 14 days may show periosteal new bone
- Bone scan if the diagnosis is still unclear
- Bloods and inflammatory markers if febrile or unwell, to exclude infection
- Skeletal survey if the history or pattern suggests non accidental injury
Differential Diagnosis
- Septic arthritis or osteomyelitis
- Non accidental injury
- Other occult toddler fractures, calcaneus, cuboid and buckle fractures
- Transient synovitis
- Leukaemia or tumour
Management
- Cast or walking boot for comfort, 2 to 3 weeks
- Above or below knee cast acceptable
- Some children manage without immobilisation
- Follow up radiographs are seldom needed if the diagnosis is clear
- Return to normal activity as comfort allows
Complications
- Rare, healing is reliable
- Missed non accidental injury is the main concern
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.