September 2021 – RCEMLearning India

Author: Mark Winstanley, Andy Neill, Dave McCreary, Nicki Abela, Bimal Mehta, Michelle Tipping / Codes: / Published: 03/09/2021

New in EM - cast v boot toddler fracture

Clinical Question

Can we use CAM boots instead of POP for Toddler’s Fractures?

Title of Paper

Randomised controlled trial comparing

immobilisation in above-knee plaster of Paris to

controlled ankle motion boots in undisplaced

paediatric spiral tibial fractures

Journal and Year

EMJ. 2021.

Lead Author

Kate Bradman

Background

– [Toddler’s fracture](https://radiopaedia.org/articles/toddler-fracture): an un-displaced, isolated, distal third (though this study just says anywhere midshaft) diaphyseal fracture of the Tibia in a child of 9m – 3 years.
– It was first described by Dunbar et al. in 1964 along with the recommendation that it be treated in a non-weight bearing above knee plaster just like you would for a grown up.
– Surprisingly, in some places the management hasn’t much changed since then.
– Other fractures are managed with early weight bearing to promote faster healing and precent muscle wasting, altered gait etc.
– CAM boots (depending on where you work) are routinely used for ankle injuries are designed to control movement of fractures while allowing weight-bearing.
– I say depending on where you work because their expense can make them unheard of in your Emergency Department, with them being reserved for physiotherapists, orthotics departments, or fracture clinic.
– Theres some (retrospective chart review) evidence that CAM books are effective and safe to use for toddler’s fracture.
– So what is needed was a prospective randomised study to assess just that – and that’s what this study ***probably isn’t**.*

Study Design

– Single centre, prospective RCT of AK-POP vs CAM boot in proven or suspected toddler’s fracture in the ED
– Tertiary children’s hospital, Perth, WA

Patients Studied

Inclusions

– 1-5 year olds
– Confirmed or suspected toddler’s fracture

Exclusions: ?NAI, displaced fracture, recent fracture <6 months, underlying bone conditions

Intervention

– Controlled Ankle Motion (CAM) boot

Comparison

– Above knee Plaster of Paris with WBAT from 7-10 days

Outcomes

– Primary: Assessment of ADLs (Specifically personal care) on modified Care and Comfort Questionnaire (CCQ) at 5 time-points: Day 1, Day 2, Day 7-10, Fracture Clinic (4-6/52), 6-8/52 (phone)
– Sections of the CCQ include:
– Personal care (putting on pants, changing nappies etc)
– Positioning
– Comfort
– Interaction

Secondary

– The other three sections of the CCQ
– Complications of fracture healing
– Pressure areas
– Weight-bearing status

Summary of Results

Patients

– 81 in final analysis
– 87 randomised, couple of exclusions for mis-diagnosis (1 x displaced tibial #, 2 x distal femoral buckle #s), 3 parental withdrawals
– 68% had radiographic evidence of # at enrolment (31 CAM, 28 POP)
– 29% had ?fracture but nil on X-ray (10 CAM, 15 POP)
– 28% of these (7/25) went on to have confirmed # (4 CAM, 3 POP)
– Age and mechanism similar across groups

Outcomes

– **Primary**: PC-CCQ better for CAM group at all time-points, greatest difference at 4 weeks (when parents are likely most fed up with the POP)
– **Secondary**:
– **Pain**: no difference until Doc (though not the parents) assessment at ortho clinic (4/52)
– Mean diff 3.52 [1.2-5.81]
– Not blinded?
– **Weight-bearing** status at 7-10 days: 77.5% CAM vs 53.8% POP (p = 0.027)
– No difference by 4 weeks
– Persistent partial weight-bearing at 6-8 weeks higher in POP group (22% vs 3% p=0.003)
– **Parental satisfaction** out of 5
– 4 for CAM
– 2 for POP

Adverse effects

– One patient changed CAM to POP for fracture widening – apparently was minimally displaced initially but not identified until review – analysed under ITT
– One patient had another fall mobilising in CAM with pain so changed to POP
– No difference in pressure areas

Authors Conclusion

This study provides trial-level evidence for moving forward from current immobilisation techniques of AK-POPs established in the 1960s and supports recommendations that all undisplaced spiral mid-shaft tibial fractures be immobilised in a below knee CAM boot.

Clinical Bottom Line

It’s not exactly surprising that a primary outcome which is effectively “is it harder to look after a Toddler when they’re wearing a full leg POP or when they wear something you can take off at your convenience?” that you find in favour of the CAM Boot. But that’s not really the question I wanted them to answer here.

I suppose they demonstrate that a CAM boot is a reasonable and safe treatment for toddler’s fracture and that there didn’t seem to be any negative outcomes – there are a couple of retrospective studies in their reference list that show this. It would just have been nice if this is what they had tested as a primary outcome here.

Regardless – my practice isn’t going to be (because it already wasn’t) above knee immobilisation for these kiddies – I’ll be going for CAM/BK backslab/soft bandage depending on patient’s pain and parental wishes. I find it hard enough to dress my kid without a plaster on…

Other #FOAMed Resources / References:

Alder Hey Hospital’s Orthopaedics Approach to Managing Children During the COVID Pandemic

bscos.org.uk – advice for Toddler’s fracture = soft bandage, no follow up. FYI.