Important News for Your Toddlers

As many kids become old enough to start walking on their own, many new challenges await the fledgling parents. Their children will want to approach and inspect everything they see, and often times they will not pay attention to where they are going leading to considerable bumps and bruising. But what if this leads to more serious injuries?

Occasionally at the FFLC, we will be consulted by our peers to treat atypical injuries arising from "freak accidents". Sometimes this occurs at a friend's house, other times it happens during the 4 seconds you are not able to see the child. Regardless gettting an accurate history about the injury is key to determine the treatment required for each injury and often times this is not possible. Sometimes the pattern or location of the injury may give the missing information some element of certainty.

Fractures in the long bones of toddlers is somewhat common, however it may happen with subtle force.

Typical symptoms include pain, refusing to walk or bear weight and limping -bruising and deformity are absent. On clinical examination, there can be warmth and swelling over the fracture area, as well as pain on bending the foot upwards (dorsiflexion). The initial radiographical images may be inconspicuous (a faint oblique line) and often even completely normal. After 1-2 weeks however, callus formation develops. The condition can be mistaken for osteomyelitis, transient synovitis or even child abuse. Contrary to CAST fractures, non-accidental injury typically affect the upper two-thirds or midshaft of the tibia.

Other possible fractures in this area, occurring in the cuboid, calcaneus, and fibula, can be associated or can be mistaken for a toddler's fracture. In some cases, an internal oblique radiography and radionuclide imaging can add information to anterior-posterior and lateral views. However, since treatment can also be initiated in the absence of abnormalities, this appears to have little value in most cases. It could be useful in special cases such as children with fever, those without a clear trauma or those in which the diagnosis remains unclear. Recently, ultrasound has been suggested as a helpful diagnostic tool if one is able to distract the youth long enough to allow a clear still leg to be examined with the ultrasound probe.

Pathophysiology
The proposed mechanism involves shear stress and lack of displacement due to the periosteum that is relatively strong compared to the elastic bone in young children. Very little is known as to the extent of the fall itself, or rather the typical fall necessary to induce this fracture pattern, but one clinical finding is never ignored: proximal tibial fractures and rib bruising with restrained behavior or timid demeanor.

It has been postulated, that multiple fractures in the absence of proven abuse or neglect, may require genetic testing to rule out underlying bone metabolizing disorders as well as other inheritable diseases. Some papers with the intent on clinical guideline development have theorized that 4 or more fractures in a 12 month period in toddlers is considered pathologic, and further testing is indicated. Others suggest that if a family history or in children whereby the familial genetics are unknown, immediate testing should be undertaken to better diagnostically evaluate the patient.