Patient Details:
- Age: 2 years old
- Presenting Complaint: Refusal to walk and increased irritability
Background: A 2-year-old boy presented to Access Ortho with a history of refusal to walk for a week. His mother reported that he had become increasingly irritable, refusing to walk, and instead dragging himself around on his bottom. The child had also been asking to be picked up frequently. The mother initially sought advice from their GP, who had ordered an X-ray, but no abnormality was noted. The child was sent home with no further investigation at that point.
Despite this, the child’s symptoms persisted, and his discomfort remained evident. At the suggestion of a family friend, the mother brought him to Access Ortho for a second opinion.
Clinical Presentation: Upon arrival, the child was visibly upset and reluctant to move his leg. His mother mentioned that although she couldn’t recall a specific incident where the child might have injured himself, she noted that the symptoms started after a play session with his cousin. During this play he had taken a tumble from the bed, and although the child had not shown any visible injury at the time, it seemed that the onset of symptoms correlated with this event. It’s important to highlight that the exact moment of injury is often difficult to pinpoint, particularly in toddlers, as they might not be able to verbalise or recall the event in detail.
Assessment and Examination: The medical team at Access Ortho conducted a thorough history and physical examination. The child was unable to bear weight on his leg and displayed discomfort when the affected leg was gently manipulated. There was localised tenderness in the lower leg, particularly around the tibia. Despite no obvious bruising or swelling, the physical signs raised concerns for a possible fracture.
The team proceeded with a further radiological assessment. While the initial X-ray had been negative, the orthopaedic specialists knew that toddler fractures, particularly subtle ones, can sometimes be overlooked on standard X-rays. Often, fractures in toddlers can be small, non-displaced, or in areas that are not immediately obvious without an orthopaedic-trained eye. A follow-up X-ray was obtained, and it revealed a toddler’s fracture, a type of spiral fracture commonly seen in children of this age, especially after falls or twisting injuries. These fractures are often subtle and can be missed on initial X-rays if not evaluated by an orthopaedic specialist who is trained to identify such subtle signs.
Diagnosis:
- Toddler’s fracture (spiral fracture of the tibia).
Management: The child was treated with a long leg cast to immobilise the leg and ensure proper healing. The medical team provided detailed instructions on caring for the cast, including keeping it dry, toileting with the cast, and signs to watch for that could indicate complications, such as increased swelling, changes in skin colour, or persistent pain. Pain management advice was also given, including over-the-counter medication for managing discomfort and tips for ensuring the child remained as comfortable as possible during the recovery period.
Follow-Up and Recovery: The child returned to Access Ortho for a two-week follow-up with the orthopaedic surgeon, where it was confirmed that the leg was healing well. The child was advised to continue wearing the cast for a total of four weeks, and the parents were reminded to restrict the child’s activities to prevent strain on the healing bone.
After four weeks in the cast, the child returned to the clinic for a cast removal. The parents were advised on how to transition the child back to normal activities, but they were cautioned to avoid high-impact activities or excessive jumping for another couple of weeks to allow the fracture to heal fully. This period of rest ensured that the healing process was not disrupted and allowed for a full recovery.
At a final four-week follow-up, the child attended the clinic, presenting as a typical, happy, active 2-year-old; they had made a full recovery and were back to their usual self, engaging in normal activities without discomfort or limitations. The tibia was fully healed, and the child resumed their typical activities without further issues.
Discussion: This case illustrates an important point regarding paediatric fractures. It is not uncommon for parents to be unsure of the exact cause of injury, especially when the child is too young to communicate clearly. In this case, while the child’s symptoms began after playing with his cousin and tumbling off the bed, the exact moment of injury was not clear. This is common in toddlers, as they often cannot verbalise the nature of the injury.
Additionally, toddler fractures can be subtle and difficult to detect on standard X-rays, especially in very young children. The lack of an obvious injury on the first X-ray led to an initial misdiagnosis. However, with the expertise of orthopaedic specialists at Access Ortho, a more detailed assessment led to the correct diagnosis. This highlights the importance of seeking specialist care when symptoms persist despite normal initial imaging. Toddler fractures are common but can often be missed if not thoroughly examined by professionals with specific training in paediatric orthopaedics.
Conclusion: This case shows the importance of a thorough clinical assessment, especially in young children presenting with unexplained pain or difficulty in walking. Despite initial normal X-rays, the child’s symptoms were carefully evaluated, leading to the diagnosis of a toddler’s fracture. With timely intervention, proper cast care, and a clear follow-up plan, the child made a full recovery, and had returned to normal activities within a few weeks. Parents should be reassured that with appropriate care and guidance, children recover well from common injuries like toddler fractures, and early intervention can help ensure a smooth and complete healing process.