Examining the cause of limp in a toddler

A toddler is brought in with a limp and no history of trauma. Dr Keith Barnard explains.

I was concerned when Mrs Brandon came into my surgery with her 21-month-old daughter Chloe. 'She's been limping all day and now she cries whenever she tries to walk.' The little girl looked quite happy, so I started with the obvious question: 'Has she had a fall?'

Mum was suddenly fighting tears. 'That's the trouble, doctor. She hasn't done anything, you must believe me.'

I briefly considered that she was protesting too much, but her anguish convinced me she was telling the truth. 'There's really nothing to tell. She was fine yesterday, running around everywhere, she's so active. And then this morning I noticed she seemed to be protecting her right leg. I thought she'd just twisted it or something, she's always falling over, but she has been like this all day.'

'Put her down over there,' I said, pointing to the far side of the surgery. Chloe, prompted to return to the safety of her mother's arms, got to her feet, hobbled a few steps then sat down and whimpered.

My first thought was irritable hip, but there was full pain-free movement, and her knees and ankles were equally normal. There was no redness or swelling anywhere, and I palpated down her leg but found no obvious tenderness.

She didn't seem too happy when I pressed around her lower shin on the right, but there was nothing to see and no specific tender spot. Despite the lack of findings, there was obviously something amiss, and I felt justified in sending her to A&E with an X-ray request, asking the casualty officer take a look at her.

The next morning Mrs Brandon left a message asking if I would ring back. I felt anxious - had they found a bone tumour? What had I missed?

'I just wanted to thank you for sending Chloe for an X-ray. They told me she had a toddler's fracture.' I had to dredge my memory to recall that this was a spiral fracture of the lower tibia in very young children. 'They said I wasn't to worry about it. The doctor said it's caused by a minor twist or fall.'

A common cause
Afterwards I checked the diagnosis. I was reminded that a toddler's fracture is a non-displaced spiral fracture of the distal third of the tibia, usually resulting from a fall that causes twisting torque on the lower leg.

It is the most commonly identified fracture in preschool-aged children presenting with a limp, often when the toddler is just learning to walk. However, the fracture can occur in children as old as six. It is thought that the injury may occur when the toddler steps on something or loses their footing, resulting in sudden twisting of the tibia.

Sometimes there is definable tenderness or redness in the area of the fracture. Internally rotated, oblique films can help identify the fracture.

Careful examination of images is required and should reveal a subtle, oblique lucency traversing the distal tibial diaphysis and metaphysis. If the diagnosis is strongly suspected, repeat X-rays taken in seven to 10 days may then show the fracture or a periosteal reaction.

Treatment may be with a cast that is put in place for variable lengths of time according to local practice and the severity of the injury. This may be from as little as 14 days to as long as six weeks. It is worth noting that in missed cases with a late diagnosis, a normal recovery still ensues. The main benefit of the cast may be to ease pain and eliminate limping.

Chloe was in a cast for three weeks, after which she resumed her playful activity with no ill effects.

Dr Barnard is a former GP in Fareham, Hampshire

LESSONS LEARNT

  • Toddler's fracture often occurs following a minor injury that is not witnessed.
  • A non-accidental injury should be considered and investigated appropriately if this is suspected.
  • The differential diagnosis includes hip dysplasia, septic arthritis, osteomyelitis and neoplasia.
  • If, after 10-14 days, a suspected case of toddler's fracture still has no X-ray evidence, bone scanning or MRI should be considered.

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