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A removable boot resulted in no difference in pain scores compared with a cast for a toddler’s leg fracture, but it was easier on caregivers for bathing and carrying, according to a pragmatic, noninferiority trial presented at the Pediatric Academic Societies (PAS) 2025 meeting.

Children wearing boots also returned to their baseline activities sooner compared with those wearing casts, Ariane Boutin, MD, MSc, of CHU Sainte-Justine Mother and Child University Hospital Centre in Montreal, Quebec, Canada, reported.

Lower extremity fractures are common in children aged 9 months to 4 years, typically a distal oblique, transverse, or buckle fracture with no or minimal displacement (< 2 mm), Boutin told attendees. These are stable fractures with an excellent prognosis, but there is practice variation in immobilization and follow-up.

Boutin therefore conducted a trial to compare pain scores in children 4 weeks after injury who wore either a removable walking boot or a circumferential cast. The trial enrolled 129 children, aged 9 months to just under 4 years, from four Canadian pediatric emergency departments between October 2019 and February 2024.

All the children had an isolated, undisplaced leg fracture apparent on x-ray. Children were excluded if it had been more than 5 days since the injury, if it was an occult fracture, abuse was suspected, or the fracture was associated with bony, metabolic, or neuromuscular disease.

One group of 64 children received a circumferential cast for 3 weeks, whereas the other 65 children wore a removable boot for 1-3 weeks. Some children were lost to follow-up or crossed to the other immobilization method, leaving 64 children with boots and 54 with casts for the 4-week follow-up.

Children in both groups were an average of 2 years old with similar rates of injury mechanism (mostly falls, followed by twists). The groups were also similar in terms of weight-bearing status, presence of focal tenderness, and fracture location, morphology, and displacement. Pain scores measured on the EVENDOL (0-15) in the emergency department were an average of 4.8 in the boot group and 5.1 in the cast group.

Four weeks after the injury, the EVENDOL scores during ambulation in the intent-to-treat analysis were an average of 1.21 in the boot group and 1.76 in the cast group, a nonsignificant difference. The per-protocol analysis also showed no significant differences (1.54 boot group vs 2.19 cast group).

Rates of complications were not significantly different between the groups, with skin rash or redness in 72% of children wearing boots and 50% of those wearing casts. Five children with boots and one with a cast had pressure sores. Itching was reported by 28% of those wearing boots and 39% of those wearing casts. None of the boots broke, but 13% of the casts broke, all nonsignificant differences.

Significantly more children wearing boots (77%) compared with casts (41%) had returned to their baseline activities at 4 weeks (36% difference, 95% CI, 9%-63%). Significantly more caregivers of cast-wearing children (72%) reported difficulty bathing their children compared with caregivers of boot-wearing children (41%). Significantly more caregivers of cast-wearing kids (68%) also reported carrying challenges vs boot-wearing kids (44%).

While caregivers’ satisfaction scores were not significantly different between the boot (80%) and cast (70%) groups, significantly more caregivers preferred the boot (80%) compared with the cast (30%).

David Frumberg, MD, an associate professor of orthopedics at Yale School of Medicine, New Haven, Connecticut, said their institution’s practice has been to avoid casting these types of fractures. “The soft tissue lining of the bone is very thick in toddlers and can give enough stability to the fracture that no cast is needed to keep the alignment acceptable and the pain minimal,” Frumberg told Medscape Medical News. “A hairline crack in the bone that does not involve the growth plate is usually the result of a twisting injury and heals very predictably.” Further, children will typically protect themselves by avoiding walking if they have pain.

“Conversely, when the fracture has healed enough, they will have less pain and will be willing to walk,” he said. “It is a better experience for the child to be able to remove a boot for bath time and sleeping when the child is comfortable.”

Ellen Szydlowski, MD, an associate professor of clinical pediatrics at Perelman School of Medicine at the University of Pennsylvania and an attending emergency physician at Children’s Hospital of Philadelphia, Philadelphia, considered the findings “exciting and encouraging.”

“We know that toddler fractures are stable injuries, so it makes sense that they may not require rigid immobilization to heal effectively,” Szydlowski told Medscape Medical News. “We’ve seen a similar trend in the management of pediatric forearm buckle fractures, which are now often treated with removable splints instead of casts.”

One downside of the boots appeared to be more cases of skin redness and pressure sores in the study, Szydlowski said, but the severity of these was not reported, and it’s possible that skin breakdown could be caught earlier and treated appropriately, whereas similar injuries in a cast may not be found until later and could become more severe.

“With provider education on proper boot fit and parental guidance on monitoring for skin irritation, these complications can be minimized and should not deter from the use of boots as an alternative treatment,” Szydlowski said. “Given these findings, removable walking boots should be considered first-line management for uncomplicated toddler fractures. It will be important to ensure that providers are trained on proper boot fitting and that families receive clear guidance on how to monitor for potential skin issues.”

The research was funded by the Physician Services Incorporated Foundation, a Canadian Association for Emergency Physicians Junior Investigator Grant, and a CHU Sainte-Justine Trauma Grant. Boutin reported no disclosures. Frumberg has consulted for Orthopediatrics, Orthofix, Kyowa Kirin, and Ultragenyx, none of which was relevant to this study. Szydlowski authored an UpToDate entry on emergency management of burns in children. 

Tara Haelle is a science/health journalist based in Dallas.