The clinical presentation and radiographs are consistent with a toddler's fracture of the tibia and the next step in management includes long leg cast application.
Mellick et al provide a review of tibial fractures in hospitalized children and describe their associations with non accidental trauma. This fracture often times presents as a gait disturbance in a young child. In this scenario, a witnessed fall in ambulatory child with avoidance of weight bearing after falling is consistent with a toddlers fracture. They provide additional recommendations regarding nonmenclature clarity for isolated spiral fractures of the tibia.
Mashru et al reviewed the treatment of tibial shaft fractures in children and adolescents. The recommendations for toddler fractures include long leg casting for only 4 weeks.
Answers 1 and 2. The radiographs demonstrate a non-displaced spiral fracture of the distal tibial shaft without signs/symptoms of infection, so MRI and aspiration are not appropriate.
Answer 3. Child abuse should be suspected with long bone fractures of the lower extremity in child who are not yet ambulatory, but in this child, this is not this case.
Answer 5. Metabolic work-up is not warranted for this common type of fracture with appropriate injury mechanism.
Heinreich SD: Fractures of the shaft of the tibia and fibula, in Beaty JH, Kasser JR (eds): Rockwood and Wilkins’ Fractures in Children, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 1077-1111
Mellick LB, Reesor K, Demers D, et al: Tibial fractures of young children. Pediatr Emerg Care 1988;4:97-101
Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. J Am Acad Orthop Surg. 2005 Sep. pii: 13/5/345. 13. (5). :345-52