A 2 year old presents with leg pain and a limp after slipping on a “slip and slide” water toy slide. X-rays are negative. The child will step when asked but will not walk on his own. Is this an occult fracture?

This is a situation where the reference standard, radiography, has limitations in sensitivity. Studies show that using alternative tests reveal evidence of fracture, such as hematoma elevation on ultrasound (Lewis J Clin Ultrasound 2006) or MRI or delayed radiographs.

You go back and examine the leg, placing “bowing” stress on the leg. Sometimes it elicits pain and sometimes it does not. You press on different parts of the leg and it is difficult to localize but there does seem to be the most pain on the distal tibia.

You then twist the leg and foot spirally and the child shouts in pain. You make a clinical diagnosis of Toddler’s fracture. On follow-up, the mother reports that the child reverted to crawling for about 4 weeks before gingerly walking and then returning to normal use of the leg in about 6 weeks. Repeat xrays in the primary physician’s office remained negative. This was an occult tibial fracture.

Take Home Points

Negative x-rays do not rule out fracture

Twisting a long-bone can elicit pain from an occult fracture, especially one in a spiral pattern


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