A 20 month old female is brought to the Emergency 
Department at about 9:00 p.m. by her parents with a 
complaint that she will not stand on her right leg since 
earlier this evening.  Parents are unsure of any trauma.  
When she cries, her parents think that her pain is 
originating from her knee.  There is no history of fever 
or prodromal symptoms, and there is no history of 
previous injuries.  Her parents report that she is able to 
walk, but with a limp.  Her past medical history is 
significant only for wheezing.
     Exam:  T37, P127, R24, BP 113/79, weight 12.8 kg.  
She is apprehensive on approach but alert and 
otherwise comfortable in no acute distress.  HEENT:  
WNL.  Neck supple.  Heart regular without murmurs.  
Lungs clear.  Abdomen is soft, flat, non-tender, with 
normoactive bowel sounds and no masses.  Color and 
perfusion are good.  Extremities:  Good range of motion 
of all joints, no deformities or effusions.  No erythema, 
warmth, or abrasions.  No definite area of tenderness 
can be determined on exam.  On observing her gait, 
she will not fully bear weight on the right leg.  She takes 
a few steps, walking very slowly with a limp.
     Some laboratory studies are obtained.  A blood 
culture is drawn.  CBC WBC 14.7, 29% segs, 66% 
lymphs, Hgb 13.3, Hct 36.7, platelets 494K.  ESR 23.  
Radiographs of both lower extremities are obtained.  
Although radiographs of both hips, femurs, tib/fibs, and 
feet were actually obtained, only her right tib/fib 
radiographs are shown.

View lower extremity radiographs.

     AP and oblique views of the tibia and fibula are 
shown, as part of a lower extremity series (includes 
hips, and femurs as well).  A true lateral view of the tibia 
and fibula was not obtained.  These radiographs are 
read as normal in the ED and the child is discharged 
and told to follow up the next day with their primary care 
physician.  The next morning, the hospital radiologist 
reviewing the E.D. radiographs notes a possible 
fracture of the distal tibia.  The child is called back to 
the E.D. where additional views of the tibia are 
obtained.

View follow-up radiographs.

     The lateral and oblique views failed to show any 
definite abnormalities.  Only the AP view of the tibia is 
shown here.  Do you see anything to confirm a 
fracture?
     This radiograph shows a definite non-displaced 
oblique fracture of the distal third of the right tibia. It is a 
thin lucency and difficult to see except on the highly 
magnified view.

View focused enlarged view.

     This view shows two radiographs of the patient's 
distal tibia.  The image on the left was taken on the 
initial E.D. visit.  The image on the right was taken on 
the follow-up E.D. visit.  By enlarging the image, the 
oblique distal tibia fracture can be seen on both views, 
but it is much harder to see on the initial E.D. visit 
radiograph (left image).

View fracture sites.

     The white arrows point to the oblique distal tibia 
fracture.  The black arrows with the white outline point 
to vascular grooves (not a fracture).  Re-examine the 
original radiographs to see if you can see the fracture 
on the original views.

View original E.D. radiographs.

     Even in the magnified view, this radiograph does not 
display the fracture site very well.  The oblique fracture 
of the distal tibia can only be seen on high 
magnification.  Darkening the room and adjusting the 
contrast and brightness on your monitor may help in 
identifying the fracture.

View follow-up radiographs.


     The follow-up views show the distal tibia fracture 
more clearly, but this is still difficult to see unless one 
looks at the radiographs very closely.  Using a 
magnifying glass to view the film would be helpful.
     On reexamination of the child during the follow-up 
visit in the E.D., the child is otherwise unchanged.  No 
tenderness is appreciated even after knowing where the 
fracture is located.  A posterior splint is applied, and the 
child is referred to an orthopedic surgeon.
     Could you comment on the etiology of this fracture?  
With no known history of trauma, would you be 
suspicious of non-accidental injury in this child (i.e., 
child abuse)?  Why or why not?

Discussion
     Fractures found in small children presenting with 
very mild or no history of trauma must alert the clinician 
to possible non-accidental injury.  However, the 
diagnosis of child abuse can bring about serious 
consequences for the suspected perpetrator, the family 
and the child.  Thus, clinicians must be very careful 
when evaluating cases of possible child abuse and not 
arrive at a conclusion too quickly.  We must be aware of 
the various conditions that can be mistaken for abuse 
and obtain an accurate history and do a thorough 
physical examination, as well as do the necessary 
studies to arrive at the correct conclusion.
     In our patient, this fracture represents a typical 
toddler's fracture described by Dunbar in 1964 as a 
subtle, non-displaced oblique fracture of the distal tibia 
in children, 9 months to 3 years of age.  The child 
usually presents with an acute onset of limp or refusal 
to bear weight on one leg.  An unsteady toddler may 
have fallen with a twist, or the child may have gotten 
his/her foot caught and fallen, twisting it while trying to 
free his/her foot.  Many times the fall is unwitnessed 
and parents are unsure of what happened.  This 
inability to give a history may prompt a clinician to 
suspect child abuse.  Children at this age are also 
unable or unwilling to give a history or localize pain.  
Also, they are at times, uncooperative with a physical 
exam.  Clinical signs of a toddler's fracture can be 
subtle with non-specific physical findings of local injury.  
Radiologic signs can also be subtle, as in our case.  
There have been cases in which initial radiographs 
were negative with fractures diagnosed only on 
follow-up studies.  The fracture may only be seen on 
the internal oblique view of the lower leg.  If all views 
are normal and one still suspects a toddler's fracture, a 
nuclear bone scan should be considered.
     In describing the toddler's fracture in 1987, 
Alexander et. al. stated that while spiral fractures can 
suggest child abuse, spiral fractures of the mid and 
lower tibia have no such implication.  In contrast, 
Tenenbein et. al. described cases in which patients 
presented with midshaft tibial fractures rather than 
distal tibial fractures.  These patients were initially 
treated as innocent toddler's fractures, then later 
presented as cases of child maltreatment.  Thus, 
Tenenbein concludes that fractures of the midshaft of 
the tibia may indicate abuse, while distal tibial fractures 
may be less suspicious.  Spiral or oblique fractures of 
the tibia are particularly common in young children 
because of the susceptibility, during their rapid linear 
growth, to bony injury from minimal trauma.  Twisting or 
rotational force through the tibia, while the ankle and 
foot are fixed, is the mechanism which would produce 
this typical injury.  Tenenbein goes on to describe that 
different locations for accidental and inflicted fractures 
may also be explained by this mechanism.  Typically, 
non-accidental injury would occur with the abuser 
holding the distal portion of the leg, twisting it, 
maximizing the force more proximally, localized to the 
midshaft of the tibia.  If the foot is fixed, the force is 
maximized more distally, as seen in accidental injury.
     Mellick and Reesor reviewed cases of tibial 
fractures, and they state that isolated spiral tibial 
fractures of children are much more commonly 
accidental.  In their radiological review of patients with 
isolated tibial fractures, they observed no differences 
between fractures judged as due to child abuse and 
those which were accidental.  Their retrospective review 
over 5 years looked at 205 children categorized as child 
abuse.  Orthopedic injuries were seen in 36 children 
and of these, 33 charts were reviewed and three had 
isolated tibial fractures.  They also go on to describe the 
CAST (Childhood Accidental Spiral Tibial) fracture, 
which is an isolated spiral tibial fracture that is not 
obscure radiologically.  This fracture often begins more 
proximally at the midshaft rather than the distal tibia.  
The approximate age range is described as 2 years to 6 
years.  Although overlapping with the age range of the 
toddler's fracture, the CAST fracture occurs commonly 
in older children.  They consider the toddler's fracture 
as a subset of the more common CAST fracture.  Thus, 
one can see that in the case of an isolated spiral 
fracture of the tibia in a child, the characteristics of the 
fracture are not sufficient enough to confirm or dismiss 
the possibility of child maltreatment.
     Accidental fractures in general are more likely to be 
isolated (except in major multiple trauma).  Patients will 
present promptly after injury with a history that fits the 
fracture pattern.  On the other hand, fractures in a child 
resulting from child abuse may be multiple and at 
various stages of healing.  Inflicted skeletal trauma may 
involve any part of the skeleton.  The presentation is 
often delayed with an often unclear history or a minor 
injury that does not fit the fracture pattern.  For 
example, a femur fracture in a preambulatory child 
should raise the suspicion of non-accidental trauma.
     Fractures specific for abuse include 
metaphyseal-epiphyseal fractures, known as bucket 
handle or chip fractures because of their radiologic 
appearance.  Fractures of the thoracic cage (rib 
fractures, sternum), scapula, spine (spinous process, 
vertebral body) are also specific for abuse.  Highly 
suggestive fractures are multiple fractures, those of the 
hands and feet, and complex skull fractures.  Especially 
important in addition to history is the association of non 
skeletal injury (intracranial, visceral).  All children less 
than two years old suspected of abuse should have a 
complete skeletal survey or bone scan.  Those less 
than a year may not show fractures until a repeat 
skeletal survey is done after 2 weeks.  Bone scans can 
reveal occult fractures within hours of injury and can be 
helpful in detecting posterior rib fractures in infants.  
Although more sensitive than X-rays, bone scans are 
less specific.
     There are multiple conditions conditions that cause 
fractures which are mistaken for child abuse.  
Osteogenesis Imperfecta (OI) is a group of heritable 
conditions in which abnormal collagen formation results 
in osteoporosis and increased susceptibility to fractures.  
OI Types II and III (the most severe forms), are 
diagnosed at delivery.  Children have extreme 
osteoporosis and are born with multiple fractures and 
deformities and have blue sclerae.  Milder involvement 
is seen in children with OI Types I and IV, although 
those with fractures show cortical thinning on X-ray.  
They have mild short stature with lower extremity 
bowing and dentinogenesis imperfecta.
     Blue sclerae, lax ligaments and a family history of 
hearing impairment are seen in most patients with OI 
Type I, the most common type.  Skull radiographs may 
reveal wormian bones.  Although the mechanism fits 
the fracture pattern, there is less force than usual.  The 
greatest difficulty in diagnosing OI, is in OI Type IV.  
Osteopenia may not be apparent in a child presenting 
with a fracture as they may not have blue sclerae or 
abnormal teeth.
     Because of frequent fractures and easy bruising, the 
concerns of abuse may arise in children with OI.  
Metaphyseal fractures resembling injuries of abuse can 
occur, although spiral or transverse fractures are most 
common.  Multiple cases of OI have been mistaken for 
abuse, although one must realize that OI is less 
common than child abuse.  Cases where child abuse 
occurs in children with OI have also been reported.  If 
one suspects OI, a punch biopsy of skin for analysis of 
collagen synthesis should be done.
     Demineralization from disuse seen in children with 
cerebral palsy and severe neuromuscular disease can 
also lead to cortical thinning making these patients 
vulnerable to fractures, thus mistaken for abuse.  Bone 
cysts may occur near the metaphyseal ends of long 
bones causing cortical thinning.  Similar pathologic 
fractures may occur at sites of osteomyelitis or in 
portions of bone replaced by tumor.  Other conditions 
that may produce fractures mistaken for abuse include 
congenital syphilis, Vitamin D deficiency rickets, copper 
deficiency, Menke's kinky hair syndrome, scurvy 
(Vitamin C deficiency), hypervitaminosis A and 
leukemia.
     Thus, in addition to the toddler's fracture seen in our 
patient, there are multiple conditions that produce 
fractures in children that can be mistaken for abuse.  
Although one must consider abuse as a possible 
diagnosis in suspicious fractures, especially with an 
unclear cause, we must also be very thorough in our 
history-taking and examination, as well as obtain the 
appropriate studies.  We must be familiar with the type 
of fractures specific for abuse and be able to consider 
other conditions that may lead to fractures.  This careful 
consideration can help avoid serious long term 
consequences for everyone involved.

References
     1.   Alexander JE, Fizrandolph RL, McConnel JR:  
The limping child.  Curr Probl Diagn Radiol 
1987;16:231-270.
     2.  Bays J.  Conditions Mistaken for Child Abuse.  
In:  Reece RM.  Child Abuse:  Medical Diagnosis and 
Management, Malvern, Pennsylvania, Lea & Febiger, 
1994, pp. 23-53.
     3.  Davis HW, Carrasco M.  Child Abuse and 
Neglect.  In:  Zitelli B, Davis HW (eds).  Atlas of 
Pediatric Physical Diagnosis, 2nd ed., New York, NY, 
Gower Medical Publishing, 1992, pp. 6.1-6.30.
     4.  Davis HW, Zitelli BJ.  Child hood injuries:  
Accidental or inflicted?  Contemporary Pediatrics 
1995;12 (1):94.
     5.  Dunbar JS, Owen HF, Nogrady MM, et al.  
Obscure tibial fracture of infants the toddler's fracture.  
J Canad Assoc Radiol 1964;15:136-144.
     6.  Gahagan S, Rimsza ME.  Child abuse or 
osteogenesis imperfecta:  how can we tell?  Pediatrics 
1991;88(5):987.
     7.  Mellick LB, Reesor K.  Spiral Tibial Fractures of 
Children:  A Commonly Accidental Spiral Long Bone 
Fracture.  Am J Emerg Med  1990;8:234-237.
     8.  Merten DF, Cooperman DR, Thompson GH.  
Skeletal Manifestations of Child Abuse.  In:  Reece RM.  
Child Abuse:  Medical Diagnosis and Management, 
Malvern, Pennsylvania, Lea & Febiger, 1994, pp. 23-53.
     9.  Tenenbein M, Reed MH, Black GB.  The 
Toddler's Fracture Revisited.  Am J Emerg Med  
1990;8:208-211.