What is the diagnosis?

The patient has a spiral fracture of the distal tibia. The X-Ray findings are subtle in the anterior view, but much more detectable on the lateral.

 Image 2. Xray of the left foot. Annotations by author. Case courtesy of Fadi Ali, Radiopaedia.org, rID: 84977

• Pearl: This is affectionately called a “Toddler’s Fracture” in children less than 3 because they commonly occur in newly ambulating children. In general, these should not raise concern for abuse in the absence of other concerning findings (delayed presentation, inconsistent story, concomitant injuries, previously known to case management) [1,2]. See here for more information.

How should this fracture be splinted in the ED?

Traditionally, these spiral fractures were splinted with long posterior splints. However, recent data suggests that outcomes are comparable with short posterior splint or a CAM walking boot. Both are better tolerated, particularly in pediatric patients [1,8].

Image 3: Posterior short leg splint [3].

In what anatomical position should the splint be applied?

The ankle should be held in 90 degrees of flexion. During the application of the splint, if tolerated, the patient should be positioned as seen in figure 3, with the patient lying prone with the knee and ankle flexed at 90 degrees. This prevents shortening of the achilles [3,4].

• Pearl: Be sure to provide enough padding at the heel, as areas of angulation on splints are at high risk of rubbing and creating pressure ulcers

What is the origin and insertion of the splint?

Origin: 2 inches distal to the fibular head, as this avoids compression of the common peroneal nerve

Insertion: Plantar surface of the distal metatarsal heads. This can be extended to the phalanx of the great toe should the fracture be located at the distal metatarsal head or phalanx [3,4].

For what other pathologies can this same splint be used?

The posterior short leg splint is versatile. It is the go-to splint for isolated tibia and fibula fractures, stable malleolar fractures, acute foot fractures (including tarsal bones, metatarsals, and phalanx bones), and even some phalanx fractures [4,5]. 

• Pearl: While the posterior splint can be used in distal metatarsal and phalanx fractures, these are often more efficiently treated via removable braces. See the table below for acceptable alternatives. 

In what cases is a stirrup splint more appropriate?

Stirrup splints provide comparable ankle stability to posterior leg splints, however these can be employed alone in nondisplaced malleolar fractures or reduced ankle dislocations. They are best used in conjunction with posterior short leg splints for reduced unstable ankle fractures [3-5].

Figure 4: Ankle stirrup splint [3].

• Pearl: When in doubt, using an posterior splint and ankle stirrup together is appropriate to ensure multiplanar stability

See Appendix A for a quick reference guide to selecting appropriate lower extremity splints and Appendix B for a reference of how to correctly position the splints.