Sonographic Diagnosis of Toddler’s Fracturein the Emergency Department

David Lewis, FCEM, Peter Logan, FACEM

The Ipswich Hospital NHS Trust, Heath Road, Ipswich, Suffolk IP4 5PD, United Kingdom

Received 15 March 2005; accepted 10 October 2005

ABSTRACT: We describe 3 cases of toddler’s fracture

of the tibia that were diagnosed via sonographic ex-

amination. In cases, initial radiographs did not show

the fracture, whereas sonographic examination re-

vealed a layer of low reflectivity superficial to the tib-

ial cortex and an elevated periosteum, suggesting a

fracture hematoma. The diagnosis was confirmed at

2–3 weeks with radiographs demonstrating periosteal

reaction. Both fractures were treated with cast immo-

bilization for 4 weeks and made a full recovery. The

third case was diagnosed via sonography and was

confirmed by the initial radiographs. These results

strongly suggest that sonography can detect the pres-

ence of a fracture hematoma and thus may help diag-

nose this injury earlier. VVC 2006 Wiley Periodicals, Inc.

J Clin Ultrasound 34:190–194, 2006; Published online

in Wiley InterScience (www.interscience.wiley.com).

DOI: 10.1002/jcu.20192

Keywords: ultrasonography; fracture; tibia; toddler;

preschool; musculoskeletal system

The limping child is a common presentation inthe emergency department. There is often no

history of significant trauma in such cases, andexamination can be inconclusive. If radiographsof the lower limb reveal no abnormality, the inex-perienced clinician may not consider the diagno-sis of toddler’s fracture.

Toddler’s fracture was first described in thedistal tibia by Dunbar et al1 in 1964. The termhas since been expanded to include occult frac-tures at other anatomical sites in this age group,including fractures of the upper tibial metaphy-sis, calcaneum, talus, and cuboid and metatarsalbones.2 Toddler’s fracture can therefore be de-fined as an occult or subtle fracture in the lower

limb of a preschool-aged child following a minortrauma.

The incidence of toddler’s fracture has beenreported to be between 0.6–2.5 per 1,000 new pe-diatric patients.3,4 It is not known in how manyof these children the diagnosis is missed becauseof the subtle features of the injury and the oftennormal appearance of an initial radiograph.

The lack of reported complications in the liter-ature suggests that the prognosis for these frac-tures is very good with or without early castimmobilization. Nevertheless, early diagnosiscan provide pain relief and parental reassurance,and may prevent unnecessary investigation torule out a more serious pathology. It also mayprevent unnecessary immobilization in childrenwho have no bony injury.

The ability to demonstrate occult foot fracturesin children and adults using sonography has beenreported previously.5–7 All of these reports usedsonography to demonstrate a discontinuity in thebone cortex to confirm the presence of a fracture.

We present 3 patients in whom toddler’s frac-ture of the tibia was diagnosed in the emergencydepartment using sonography to demonstrate alayer of low reflectivity superficial to the tibialcortex with periosteal elevation, suggesting afracture hematoma. The diagnosis was confirmedby later radiographs in all 3 children.

Sonography was performed by the same emer-gency room physician in all 3 cases. A SonoSite180 Plus (SonoSite Inc, Bothell, WA) was usedwith an L38 linear-array 10–5-MHz broadbandtransducer.

The procedure was explained to the parentand the child was demonstrated initially on theparent to reassure the child. The examinationwas initiated at the site of maximal warmth butincluded the entire tibia length and approxi-

Correspondence to: D. Lewis

' 2006 Wiley Periodicals, Inc.

190 JOURNAL OF CLINICAL ULTRASOUND—DOI 10.1002/jcu

Case Report

mately one third the circumference. Maximumresolution was used, and the depth was adjustedto maximize magnification of the region superfi-cial to the tibial cortex. Longitudinal images ofthe anteromedial subcutaneous aspect of the tibiawere obtained. The other limb was also examinedfor comparison.

The examination lasted less than 5 minutesand was well tolerated by all 3 children. A radiol-ogist interpreted all radiographs within 24 hours.

CASE REPORTS

Case 1

An 18-month-old boy presented to the emergencyroom after a fall 24 hours previously. He had been

refusing to bear weight on the right leg since thefall.

The child had previously been fit and well andwas taking no medications. On examination, hewas apyrexial, comfortable at rest, and reluctantto transfer weight through his right leg. Therewas no swelling, bruising, or deformity visible,and his range of motion was normal. There wasno focal tenderness, but the examining physicianwas unable to rule out lower leg tendernessbecause of inconsistent responses from the child.

Plain radiographs of the right leg failed todemonstrate bony injury (Figure 1A). A diagnosisof soft tissue trauma was made, analgesic medi-cations were prescribed, and a 72-hour reviewwas arranged.

At review, the child was still non-weight-bear-ing and had been having trouble sleeping. Exami-

FIGURE 1. Case 1. (A) Plain anteroposterior (left) and lateral (right) radiographs of the right tibia at day 1 show a normal appearance. (B) Longitu-

dinal sonogram of the right tibia (middle third) at day 3 shows periosteal elevation with an underlying fracture hematoma appearing as a hypo-

echoic strip between the periosteum and cortex less than 2 mm wide (arrows). (C) Plain lateral (left) and anteroposterior (right) radiographs of the

right tibia at day 14 show periosteal elevation/reaction in the region of the middle third of the tibia (arrows).

SONOGRAPHIC DIAGNOSIS OF TODDLER’S FRACTURE

VOL. 34, NO. 4, MAY 2006—DOI 10.1002/jcu 191

nation revealed an area of localized warmth overthe distal right subcutaneous tibia. Sonographicexamination revealed a subperiosteal hematomain this area suggestive of toddler’s fracture (Fig-ure 1B). The leg was immobilized in an above-knee cast and was reviewed at 2 weeks, at whichtime a plain radiograph demonstrated a healingoblique fracture of the distal tibia (Figure 1C).The cast was removed at 3 weeks, and the childrapidly returned to normal activity.

Case 2

A 2-year-old girl presented to the emergencyroom refusing to bear weight on her left leg afterbouncing on a trampoline the same day, but shehad no obvious history of trauma. She was previ-ously fit and well.

The child was apyrexial, but distressed andcrying, with no definite deformity of the leg, fullrange of motion at all joints, and no focal tender-ness. There was no warmth or erythema to theleg, but a slight swelling was visible in the softtissues around the knee.

Plain radiographs failed to demonstrate bonyinjury (Figure 2A); thus, a provisional diagnosisof soft tissue injury was made. The child wasallowed to return home with appropriate analge-sia and a review 4 days later.

At review the child was still refusing to bearweight on her leg and appeared to be focally ten-der in the distal half of the tibia. Sonographic ex-amination revealed the presence of a subperios-teal hematoma that was most prominent over themiddle third of the tibia (Figure 2B). A diagnosisof toddler’s fracture was made, and the limb wasimmobilized in an above-knee cast.

Repeat plain radiographs at 3 weeks demon-strated a healing upper tibial transverse hyper-extension fracture (Figure 2C). On cast removal,the child rapidly returned to normal activity.

Case 3

A 2-year-old boy presented to the emergencyroom having fallen while playing at an activitycenter. He was not bearing weight on his right leg.

On examination, localized warmth was pres-ent over the lower shin. The child’s range ofmotion of the hip and knee were full and non-painful. Sonography of the right lower leg demon-strated an elevated tibial periosteum suggestiveof fracture hematoma (Figure 3A). Plain radio-graphs confirmed this diagnosis, showing anundisplaced spiral fracture of the distal tibia(Figure 3B).

The child was treated with an above-knee castand made an unremarkable recovery.

DISCUSSION

Toddler’s fractures are difficult to diagnose. Inthe classical toddler’s fracture, a nondisplacedoblique fracture of the distal tibia, the sensitivityof a standard series of radiographs is 52–56%.3,8

In upper tibial transverse hyperextension frac-tures, the sensitivity is less than 38%.9

Following an injury to bone and periosteum,the hematoma accumulates within the medullarycanal at the fracture site, beneath the elevatedperiosteum and extraperiosteally whenever theperiosteum is disrupted during fracture. Perios-teum in children is thick and much less likely tobe disrupted around the entire circumference ofthe bone; it strips away easily from the underly-ing bone, allowing the fracture hematoma to dis-sect along the diaphysis toward the metaphysis,where it becomes more firmly attached. Perios-teum attaches densely into the peripheral physis,blending into the zone of Ranvier as well as theepiphyseal perichondrium. The zone of Ranvier isa specialized region at the periphery of the physisthat allows growth by cellular addition (apposi-tional growth). Dense attachment of the perios-teum at the zone of Ranvier limits the spread ofsubperiosteal hematoma to the metaphysis anddiaphysis.10,11

It is this hematoma that is responsible for thepresence of increased warmth over the distal tibiain toddler’s fractures. When present, this sign isvery sensitive–although it does not have a highnegative predictive value.3,8 Some hematomas maynot be large enough to produce a detectable differ-ence in temperature between either leg, though allof our cases demonstrated a difference. Whetherthe smaller hematomas would be detectable withsonography requires further evaluation.

Case 3 demonstrates that the fracture hema-toma is present and acutely detectable via sono-graphy. Without prospective analysis of this diag-nostic test, we do not know its sensitivity andspecificity for toddler’s fracture. However, as arule-in test and with no significant disadvan-tages, it is a useful addition to the diagnosticoptions available for toddler’s fracture. This ex-amination was well tolerated by all 3 children inthis series, however, the technique does requirethe limb to be held still long enough to acquire ahigh-quality image. In practice, success will de-pend on the skill and experience of the sono-grapher and the compliance of the child.

LEWIS AND LOGAN

192 JOURNAL OF CLINICAL ULTRASOUND—DOI 10.1002/jcu

Management of suspected toddler’s fracture isdifficult because of the difficulty in obtaining adefinite diagnosis at the time of initial presenta-tion. The majority of limping toddlers with nor-mal hips will have sustained a soft tissue injury.These children may avoid weight-bearing ini-tially and mimic a toddler’s fracture. Plain radio-graphs cannot accurately distinguish soft tissueinjury from a toddler’s fracture, leading to a man-

agement dilemma for emergency physicians. Un-necessary casting of the lower limb in a toddler isunsatisfactory for both parent and child; how-ever, a child with a true toddler’s fracture will of-ten not sleep well and may suffer extra discom-fort until a cast is applied. In children with a clin-ical picture of toddler’s fracture and a normalradiograph, sonographic examination may allowan earlier, more accurate diagnosis and thus

FIGURE 2. Case 2. (A) Plain lateral (left) and anteroposterior (right) radiographs of the left tibia at day 1 show a normal appearance. (B) Longitudinal

sonogram of the left tibia at day 4 shows periosteal elevation with an underlying fracture hematoma. (C) Plain lateral (left) and anteroposterior

(right) radiographs of the left tibia at day 1 show a healing upper tibial transverse fracture (arrow).

SONOGRAPHIC DIAGNOSIS OF TODDLER’S FRACTURE

VOL. 34, NO. 4, MAY 2006—DOI 10.1002/jcu 193

allow earlier casting in the correct group ofpatients.

REFERENCES

1. Dunbar JS, Owen HF, Nogrady MB, et al. Obscuretibial fracture of infants–the Toddler’s Fracture.J Can Assoc Radiol 1964;15:136.

2. John SD, Moorthy CS, Swischuk LE. Expanding the

concept of the Toddler’s Fracture. Radiographics

1997;17:367.3. Shravat BP, Harrop SN, Kane TP. Toddler’s Frac-

ture. J Accid Emerg Med 1996;13:59.4. Clancy J, Pieterse J, Robertson P, et al. Toddler’s

Fracture. J Accid Emerg Med 1996;13:366.5. Graif M, Stahl-Kent V, Ben-Ami T, et al. Sono-

graphic detection of occult bone fractures. PediatrRadiol 1988;18:383.

6. Wang CL, Sheih JY, Wang TG, et al. Sonographicdetection of occult fractures in the foot and ankle.J Clin Ultrasound 1999;27:421.

7. Enns P, Pavlidis T, Stahl JP, et al. Sonographicdetection of an isolated cuboid bone fracture notvisualized on plain radiographs. J Clin Ultrasound2004;32:154.

8. Tenenbein M, Reed MH, Black GB. The toddler’sfracture revisited. Am J Emerg Med 1990;8:208.

9. Swischuk LE, John SD, Tschoepe EJ. Upper tibial

hyperextension fractures in infants: another occulttoddler’s fracture. Pediatr Radiol 1999;29:6.

10. Johnstone EW, Foster BK. The biologic aspects of

children’s fractures. In: Beaty JH, Kasser JR, edi-

tors. Rockwood and Wilkins, fractures in children.

5th edition. Philadelphia: Lippincott Williams and

Wilkins; 2001. p 21.11. Ogden J. Anatomy and physiology of skeletal de-

velopment. In: Ogden J, editor. Skeletal injury in

the child. Philadelphia: Lea and Febiger; 1998.

p 16.

FIGURE 3. Case 3. (A) Longitudinal sonogram of the left tibia at day 1

shows periosteal elevation with an underlying fracture hematoma

(arrows). (B) Plain anteroposterior radiograph of the left tibia at day 1

shows an undisplaced spiral fracture of the distal left tibia (arrows).

LEWIS AND LOGAN

194 JOURNAL OF CLINICAL ULTRASOUND—DOI 10.1002/jcu