Justin was a two-year-old who came to the office because of a limp he had for over a week. He had been at a family birthday party ten days ago where many children of all ages were having a grand time. At the party two of the older cousins came to Justin’s mom saying that he had hurt himself. When she got to him he was sitting on the ground crying, saying that his right leg hurt. None of the other children had seen him fall or actually hurt himself. But a number of the kids were jumping off of a small retaining wall that was about two feet high.
When mom asked, Justin couldn’t localize exactly where his leg hurt. She could not see any obvious redness or swelling, but any movement of the leg seemed to cause him discomfort. After a few minutes and some TLC he stopped crying and seemed to be fine. He wanted to resume playing with the other children. Mom noticed he favored his right leg when he walked and had a vague limp when he continued to play with the others.
That night in his bath he seemed not to want to move the leg in certain positions. Still there was no swelling or redness. Figuring he may have sprained it while jumping, she gave him Advil and put him to bed where he fell fast asleep. The next morning when he got out of bed he winced the minute he put his right foot down and refused to walk. He crawled for a short time and then would weight bear, but he walked with a limp.
Since it was Sunday mom took him to an urgent care center. They X-rayed his leg, ankle and foot. The findings were all negative and mom was assured there was no fracture. It most certainly was a bad sprain. She was advised to use ice, ibuprofen and no weight bearing. If things did not resolve in a few days she should consult with the primary care physician.
Throughout the next week Justin intermittently seemed to be getting better. He would barely favor it when he walked, but after actively playing he would limp and say it hurt. When I saw him the following Tuesday he had no fever, was in no distress and was playful and very interactive. On inspection there was no swelling or discoloration of his legs which were perfectly symmetrical. He had strong and equal pulses on the top of his feet and could wiggle his toes. I could easily abduct his hips without any resistance or discomfort (spread them open in a frog leg position). When I went to range the knees he did resist a little as I flexed the right knee. But he let me do this with good range of motion. The same happened when I ranged the ankles. But when I flexed this foot upward he winced and pulled away. He did the same when I moved his right foot inward and outward.
I asked him to point to where exactly his leg hurt—he just pointed to his foot. Although he couldn’t localize the point of pain I felt I could elicit tenderness at the lower part of his leg, just above the ankle.
I told mom that I thought Justin had a fracture of the distal tibia (the larger bone of the lower leg). But she said the X-rays were taken and were normal. In fact she had a copy of them on a disc. Upon review they were certainly negative for a fracture. I told her that he could have a “hairline” fracture. I wanted to repeat the X-rays and have him see an orthopedist. Sure enough, the repeat X-rays showed a healing fracture of the distal tibia with a good alignment. Justin saw the orthopedist the next day. The diagnosis was confirmed and Justin was put in a cast for four weeks, since he was such an active toddler.
Toddler’s fractures are a common injury in active children. It occurs from the age of 9 months to 3 years. It is a low energy fracture which usually involves a rotational component with torque (twisting). Over 95% of these fractures occur in the distal 2/3 of the tibia. Many of them are small, subtle and can be easily missed on X-ray. Some don’t cross through the entire bone, so they do not show up on the initial X-ray. Then after the bone starts to heal itself by laying down new bone growth (callus) it is very obvious on the subsequent X-ray. This is what I saw with Justin. The initial film was negative, and the X-ray ten days later clearly showed a fracture with callus formation—commonly known as hairline fracture.
Most patients will benefit from a cast since this insures proper alignment as the bone heals and keeps the patient from overdoing it as far as weight bearing. There should be complete healing without complications in the vast majority of cases. It is wise to get a follow up X-ray in a few weeks to check the alignment and to document complete resolution.
In some cases there is not obvious X-ray findings of the fracture, even after a couple of weeks. In these cases the orthopedist may elect to cast the leg and treat it purely on clinical findings. Some may want more specific testing and will get an MRI or CT of the leg to confirm the diagnosis. There is no right or wrong answer but is left up to the physician’s comfort level.
It is the obligation of the physician to be sure that the history fits the injury. As an advocate for the child, non-accidental trauma (abuse) must always be of utmost concern and must be ruled out. As a general rule, most toddler’s fractures are small and subtle. Over 95% occur in the lower two-thirds of the tibia whereas larger spiral type fractures occurring in the proximal one-third of the tibia should raise concern for a non-accidental fracture and must be investigated thoroughly.
Justin had his cast for a total of four weeks and did just fine. His leg healed completely. It was a good thing that he did have a cast. He played as vigorously as if he didn’t have the cast at all.