The Toddler's Fracture: Accident or Child Abuse?
Radiology Cases in Pediatric Emergency Medicine
Volume 4, Case 18
Melinda D. Santhany, MD
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
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
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
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
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?
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
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
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
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.
1. Alexander JE, Fizrandolph RL, McConnel JR:
The limping child. Curr Probl Diagn Radiol
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
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
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
Return to Radiology Cases In Ped Emerg Med Case Selection Page
Return to Univ. Hawaii Dept. Pediatrics Home Page