Toddler’s Fractures

Overview

Definition

Non-displaced spiral Spiral Computed tomography where there is continuous x-ray exposure to the patient while being transported in a spiral or helical pattern through the beam of irradiation. This provides improved three-dimensional contrast and spatial resolution compared to conventional computed tomography, where data is obtained and computed from individual sequential exposures. Computed Tomography (CT) fractures of the distal tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy are often called “toddler’s fractures,” as they are commonly seen in children who are just starting to walk.

Epidemiology

• Most commonly seen in toddlers 9 months to 3 years of age, peak at 27 months
• Can be seen in children as old as 11 years of age
• Most commonly seen in tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy, but may affect all lower extremity bones
• More common in boys

Etiology

• Mechanism:
  • Younger children:
    • Low-energy twisting of foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy with fixed knee
    • Often seen in children learning to walk
  • Older children: direct trauma
• Less likely to be associated with child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse (also known as non-accidental trauma or NAT) than with metaphyseal corner or apophyseal ring fractures

Diagnosis and Management

Clinical presentation

Diagnosis of toddler’s fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures may be challenging due to lack of documented trauma and the inability of the child to localize injury:

• May present with limp, antalgic gait Antalgic Gait Legg-Calvé-Perthes Disease, or refusal to bear weight
• Delayed presentation is common.
• Systemic symptoms (e.g., fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever) should raise suspicion for infectious etiology (septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis, osteomyelitis Osteomyelitis Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus. Osteomyelitis, myositis) or transient synovitis Synovitis Inflammation of the synovial membrane. Rheumatoid Arthritis.

Signs:

• Rarely, swelling Swelling Inflammation and localized tenderness
• Tenderness to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination over distal tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy
• Gentle twisting of ankle and knee in opposite directions elicits tibial pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
• Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways may be elicited by ankle dorsiflexion.
• No obvious displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms or deformity Deformity Examination of the Upper Limbs
• Patient often more comfortable positioned in caregiver’s lap during exam

Imaging

• 2 views should be obtained (AP and lateral); additional oblique may be helpful.
• Initial X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests findings may be subtle:
  • Fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures line often faint or absent
  • May be mistaken for blood vessel
• Possible findings:
  • Spiral Spiral Computed tomography where there is continuous x-ray exposure to the patient while being transported in a spiral or helical pattern through the beam of irradiation. This provides improved three-dimensional contrast and spatial resolution compared to conventional computed tomography, where data is obtained and computed from individual sequential exposures. Computed Tomography (CT) or oblique fracture Oblique Fracture Overview of Bone Fractures mid-to-distal tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy
  • Periosteal reaction may be noted with delayed presentation.
• If X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests is negative, but high clinical suspicion, imaging may need to be repeated after 1–2 weeks to allow new periosteal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types formation.
• In some cases, other imaging modalities (e.g., magnetic resonance imaging (MRI) and bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types scintigraphy Scintigraphy Sjögren’s Syndrome) may be needed to rule out other serious diagnoses (e.g., osteomyelitis Osteomyelitis Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus. Osteomyelitis).

Management

These fractures are usually non-displaced and are managed non-operatively. 

• Supportive measures:
  • Analgesia Analgesia Methods of pain relief that may be used with or in place of analgesics. Anesthesiology: History and Basic Concepts
  • Make non-weight bearing or modified weight bearing
• Casting:
  • Long-leg cast for 2–3 weeks
  • Follow with short-leg casting for 2–3 weeks

Clinical Relevance

Essential considerations in differential diagnosis of a child presenting with a limp:

• Transient synovitis Synovitis Inflammation of the synovial membrane. Rheumatoid Arthritis: acute, self-limiting Self-Limiting Meningitis in Children inflammatory condition involving the hips. Most common cause of hip pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in children. Presents as a well-appearing child with limp or refusal to bear weight. Many patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship report a history of recent flu-like illness. Physical examination of affected side shows mild restriction of range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs with irritability of hip.
• Acute osteomyelitis Acute osteomyelitis Osteomyelitis evolves over days or weeks. Osteomyelitis: acute bone infection Bone infection Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by staphylococcus aureus. Osteomyelitis often caused by hematogenous Hematogenous Hepatocellular Carcinoma (HCC) and Liver Metastases spread of bacterial pathogen. Most commonly identified causative organism in children is Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may present with fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion, swelling Swelling Inflammation, tenderness to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination, and antalgic gait Antalgic Gait Legg-Calvé-Perthes Disease. Supportive diagnostic testing includes lab tests for inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and infection and appropriate imaging studies. Definitive diagnosis often requires biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma. Management includes parenteral antibiotics after cultures are obtained.
• Septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis: bacterial, viral, or fungal infection of joint synovial membrane Synovial Membrane The inner membrane of a joint capsule surrounding a freely movable joint. It is loosely attached to the external fibrous capsule and secretes synovial fluid. Hip Joint: Anatomy and fluid. Most common causative organism is S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus. Majority of cases are monoarticular, with hip and knee joint Knee joint The knee joint is made up of the articulations between the femur, tibia, and patella bones, and is one of the largest and most complex joints of the human body. The knee is classified as a synovial hinge joint, which primarily allows for flexion and extension with a more limited degree of translation and rotation. Knee Joint: Anatomy most commonly involved. Children usually present with decreased range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs or painful gait Gait Manner or style of walking. Neurological Examination, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, swelling Swelling Inflammation, and irritability. Synovial fluid aspiration and examination is both diagnostic and curative. Antibiotic therapy is indicated and should be started as soon as cultures are obtained.
• Osteosarcoma Osteosarcoma Osteosarcoma is a primary malignant tumor of the bone characterized by the production of osteoid or immature bone by the tumor cells. The disease is most common in children and young adults and most frequently affects growth plates of the long bones, although it can involve any bone. Osteosarcoma: most common primary malignant tumor Tumor Inflammation of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types, most frequently found around the knee, causing localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, warmth, swelling Swelling Inflammation, and limping. Has bimodal distribution Bimodal distribution Measures of Central Tendency and Dispersion affecting children (usually 10 + years old) and elderly patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.

Common fractures seen in pediatric age group:

• Greenstick fracture Greenstick fracture The bones of growing children exhibit unique characteristics, which, combined with the unique mechanisms of injury seen in children, result in fracture patterns differing significantly from those common in adults. The greenstick fracture is an incomplete fracture usually seen in long bones. Greenstick Fracture: partial-thickness fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures that involves complete break of cortex and periosteum Periosteum Thin outer membrane that surrounds a bone. It contains connective tissue, capillaries, nerves, and a number of cell types. Bones: Structure and Types on only 1 side of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types. Termed “greenstick,” as it resembles a break in a live, “green” twig, where 1 side of the stick remains intact. High risk for refracture, and therefore should be completely immobilized. Rarely requires reduction, but should be managed cautiously to prevent malunion Malunion Hip Fractures or angulation Angulation Buckle or Torus Fracture deformities; often should be referred for orthopedic follow-up.
• Supracondylar fracture Supracondylar fracture Supracondylar fractures are the most common elbow fractures in the pediatric population. The most common mechanism of injury involves a fall on an outstretched hand, resulting in a fracture of the distal humerus. Patients frequently present with pain, visible deformity, and limited range of motion of the injured elbow. Supracondylar Fracture: complete fracture Complete Fracture Overview of Bone Fractures affecting the distal humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy after falling on outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy (FOOSH). Commonly, fractures of the elbow in children. Requires immediate orthopedic consultation, as many cases are associated with neurovascular injury and require surgical intervention. 
• Buckle or Torus fracture Torus Fracture Buckle or Torus Fracture: fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures affecting growing metaphyseal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types secondary to compression Compression Blunt Chest Trauma load, where bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types buckles or compresses. Generally considered a stable fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures. Treated by immobilization Immobilization Delirium, and has a good prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas.