Spiral Tibia1Fracturesof Children: A Commonly Accidental Spiral Long Bone Fracture LARRY B. MELLICK,
MD,* KENNETH REESOR, MD,t
Pediatric training in child abuse has consistently emphasized a strong association between nonaccidental injuries and spiral fractures of long bones. Isolated spiral tibia1 fractures of childhood have previously been recognized by the orthopedic specialty to most frequently be accidental in etiology. The authors present evidence that supports a predominantly accidental etiology for isolated spiral tibia1 fractures of young children. This article presents a series in which 9 of 10 such spiral fractures were most likely the result of an accident and not child abuse or gross neglect. Additionally, almost all of these fractures presented as a gait disturbance and should be included in the differential of this complaint. (Am J Emerg Med 1990;8:234-237. 0 1990 by W.B. Saunders Company.)
Spiral fractures of long bones in young children have generally been considered evidence for child abuse by pediatricians and social workers. Typically, the formal investigation of these injuries results in significant psychological, social, and financial costs for all participants. Accidental isolated spiral tibia1 fractures of young children have been described previously.‘,’ Moreover, orthopedic literature and practice generally exhibits a greater awareness of the accidental nature of childhood spiral tibia1 fractures.3.4 Unfortunately, both pediatric and orthopedic literature have given only minimal attention to this subject. A limited physician awareness of this frequently accidental injury can result in controversial decisions by medical personnel.5 In this article we review 10 spiral tibia1 fractures of young children. Only 1 of these 10 spiral tibia1 fractures was the consequence of physical child abuse. MATERIALSAND METHODS Over a 1Cmonth period 10 reports of patients with isolated spiral tibia1 fractures were collected by the authors. These cases were evaluated to ascertain the events surrounding the injury and their possible association with child abuse. One or both parents were interviewed by the primary author concerning the events surrounding the injury. A minimum of three other physicians interviewed the parents and examined the children in the period immediately following the injury. Referrals for formal investigation of possible child abuse and neglect were made if initial examinations and interviews produced information or observations that required further clarification. Additionally, the association of child abuse and spiral tib-
ial fractures was further investigated through a 5-year review of social work service records of proven child abuse. All charts of child abuse with fractures were surveyed to investigate for isolated spiral tibia1 fractures. The charts of patients with these injuries were carefully reviewed. Through Medline a review of the literature was performed back to 1966 for all discussions of spiral tibia1 fractures. Additional references were gleaned from an exhaustive review of this literature, orthopedic textbooks, and Orthobase. Finally. a study of the roentgenographic appearance of these fractures was accomplished. An attempt was made to document anatomical characteristics of these tibia1 fractures. RESULTS Ten children with spiral tibia1 fractures were observed and studied. The injuries in nine of the children were considered accidental. A babysitter admitted to the physical assault of one patient. The single fracture resulting from nonaccidental trauma (NAT) occurred to the youngest child (9 months) and the only patient without full ambulation skills. CASE REPORTS isolated Spiral Tibia1 Fractures Case One A 36-month-old boy was playfully jumping on his father, who was lying on the floor watching television. After warning his child to stop the energetic play, the father reportedly turned to his side from the supine position. When the patient again jumped on his father, the child fell to a carpeted floor and possibly struck the leg of a table. Because the patient landed behind his father, neither parent actually observed the patient at the moment of impact. The crying child was subsequently observed lying on his back with both legs in the air and holding on to his injured left leg. Afterwards, the patient would not bear weight on the injured extremity. Within 1 hour of the injury the child was evaluated in the emergency department (ED). Examination of the left leg demonstrated mild edema, small pretibial ecchymoses. and tenderness to palpation. There was no obvious deformity. Roentgenographic study showed an isolated spiral tibia1 fracture beginning in the middle third and extending almost to the epiphysis. The patient’s leg was put in a cast for 6 weeks. There were no complications or limitations as a result of the injury, Case Two
From ‘Columbus, OH, and the tDepartment of Orthopedics, Tripler Army Medical Center, Oahu, HI. Manuscript received June 21, 1988; revision accepted July 20, 1989. Address reprint requests to Dr. Mellick: 1888 Walnut Hill Park Dr, Columbus, OH 43232. Key Words: Children, fractures, tibia, spiral, child abuse, long bone, injuries. 0 1990 by W.B. Saunders Company. 0735-8757/90/0803-0013$5.00/O 234
A 21-month-old boy was brought crying from upstairs by his 6year-old sister. No fall was observed by the sister. The patient refused to stand on his right leg. Medical attention for the patient was sought immediately. In the ED the leg showed no visible deformity, ecchymoses, or abrasion. Tenderness was noted with palpation of the midshaft of the tibia. A spiral fracture was seen to begin in the middle and extend to the distal third of the tibial diaphysis. The fracture was casted for 6 weeks and no long- or short-term complications resulted from the injury.
MELLICK AND REESOR W SPIRAL TIBIAL FRACTURES
Case Three While in the kitchen with his mother a 24month-old boy was observed to make a twisting movement and fall to the ground. Immediately, the child began crying and would not bear weight on his left leg. Examination of the patient demonstrated pretibiai tenderness and refusal to walk. A few fading circular small bruises were noted on the pretibial skin. No other physical findings were present. Again, appropriate parental interviews and patient examinations were performed. The spiral fracture located in the middle and distal diaphysis was considered accidental.
window. Subsequently, the patient would not walk on the injured leg. There was only slight swelling of the skin overlying the fractured tibia. Evaluation indicated that the injury was accidental. The fracture was casted between 5 to 6 weeks and healed without complications.
Case Eight While running during a temper tantrum a 44-month-old girl slipped on the cover of a comic book. The patient was found with her leg “backward and underneath” her body. The patient told her parents that her “leg broke”. Subsequently, the child would not bear weight on the injured leg. The patient had a previous fracture which occurred while attempting to get on an older child’s bicycle. The possibility of child abuse was discussed. After evaluation the family was not referred for further investigation of NAT. The patient was casted, followed by the orthopedic service, and had no complications associated with this injury.
The family of a 29-month-old boy had just moved into temporary military living quarters. While running in his stockinged feet the patient slipped and fell on a freshly mopped tile floor. The parents did not see the actual fall. The injury occurred at approximately 9:00 AM. Medical care was sought when the patient’s father arrived home for lunch. There was no swelling of the extremity. Roentgenographic examination of this patient’s fracture showed no displacement and was located in the distal quarter of the tibia. The parents later admitted that they were initially concerned that the “Navy” might think that they had abused their child. However, after evaluations at the Pearl Harbor naval clinic and the department of orthopedics at Tripler Army Medical Center, no formal investigation for suspected child abuse and neglect (SCAN) was initiated. The patient’s fracture was casted for 4 weeks and no morbidity resulted from the injury.
A 24-month-old boy “tangled with his sister” and fell from a weight bench in the lanai. The patient was taken to the local air force clinic because he would not bear weight on what seemed to be a “sprained ankle”. During a second visit a radiograph was obtained which demonstrated the spiral tibial fracture. Palpation of the lower leg was painful to the patient. Otherwise, there was no physical evidence of injury. The fracture was casted for 5 weeks. The patient’s recovery was uneventful.
A 39-month-old child was injured when she fell while hanging by her arms from “monkey bars”. The estimated distance from the cross bars to the ground was 6 feet. Because of a misunderstanding, neither parent caught their daughter. The patient reportedly became angry at the parents and screamed, “You broke my leg!” The injured leg was described as positioned “up under the patient” and between the other leg. Swelling or bruising of the leg was minimal. Again, the patient would not bear weight on the injured extremity. Because of the minimal external findings the patient was not taken to the clinic until the next morning. The family was evaluated in the naval medical clinic and the orthopedic clinic. The injury was considered accidental and no SCAN evaluation was performed. The fracture was casted for 5 weeks. There were intermittent pain complaints at the fracture site during the month following cast removal.
A 9-month-old boy was brought to the ED for evaluation of a left spiral tibial fracture. The parents initially had no explanation for the injury, which they first noticed after the infant was picked up from the babysitter. Shortly afterwards, the babysitter admitted to grabbing and twisting the extremity after becoming angry with the child. This patient’s case was subsequently followed by the Air Force family advocacy team.
Case Six A 40-month-old boy was playing in his brother’s cowboy boots. The patient reportedly stepped off a curb, twisted his left ankle, and fell. His babysitter observed the accident. The patient would not bear weight on the injured extremity. There were no obvious marks or swelling of the extremity to suggest an injury. During the day the patient would sit and watch television. However, in the evenings, the patient cried with pain. After 2 days the parents decided that the injury might be more than a simple “ankle sprain” and sought medical care. The parents were interviewed concerning the circumstances of the injury at the Army medical clinic and in the ED. After these evaluations no additional investigations for child abuse or neglect were performed. Subsequently, the patient was evaluated, treated and released by the orthopedic service. The patient’s spiral tibial fracture was casted for 6 weeks.
Case Seven A 34-month-old boy was pushed off the top of a picnic table by another child. The patient fell an estimated distance of 3% feet. He was found lying on the ground holding out his injured left leg. At the moment of injury the patient’s mother was on the telephone with a friend. Nevertheless, she was able to witness the accident through a
RETROSPECTIVE REVIEW OF CHILD ABUSE RECORDS Between 1983 to 1987 a total of 205 children were listed under the category of child maltreatment syndrome. Thirtysix of these children had orthopedic injuries. Thirty-three of these records were available for review. Three of these children had isolated spiral tibial fractures. Two of these patients (cases 11 and 13) were included in our first article, which reviewed hospital admissions for tibial fractures over a S-year period.
Case Eleven A 2-month-old infant presented with an isolated proximal spiral tibial fracture. The tibial injury allegedly occurred when the patient “slipped” while a parent was placing the child into a sitting position on the floor. A subsequent hospital visit, examination and admission demonstrated rib fractures and bruises on the infant’s back.
Case Twelve A 19-month-old boy was injured while jumping on the bed with his four-year-old brother. The patient fell a distance of 3 feet from the bed to the floor. When interviewed alone the older brother reiterated the same explanation for the injury as presented by the parents. Following the injury the patient would not bear weight on his right extremity. The patient was taken immediately for medical evaluation. Roentgenographic examination showed an isolated spiral fracture of the distal tibia. The patient was subsequently admitted and a formal investigation of the injury was performed. Even though no additional evidence for child abuse was obtained the outcome of the
AMERICAN JOURNAL OF EMERGENCY MEDICINE W Volume 8, Number 3 W May 1996
SCAN evaluation was suspected child abuse and neglect. The discharge note indicated that “the suspicion of child abuse cannot be ruled out due to the nature of the fracture”.
TABLE1. Descriptive Characteristics of Childhood Accidental Spiral Tibia1 (CAST) Fractures Location
Case Thirteen A lFmonth-old boy presented with an isolated spiral fracture of his distal left tibia. The patient reportedly tripped over a dog chain 3 days prior to presentation for medical care. The actual fall was reportedly not observed by either parent. The patient’s mother “thought it was only a sprain”. The family had been investigated 7 months earlier for allegedly leaving their children unattended. This previous investigation did not verify the allegations. Nevertheless, because of the delay in seeking medical care and inconsistencies in the history, the fracture was designated to be consistent with child abuse. No additional evidence or risk factors for child abuse or neglect were reported in
the medical records.
LITERATURE REVIEW A review of the literature showed only the original reference,’ in which obscure accidental spiral tibial fractures or Toddler’s fractures were fist defined, and a discussion of gait disturbances by Singer and Towbin This first article is typically the only reference to accidental isolated spiral fractures in all current orthopedic and radiology textbooks. Our recent article on tibial fractures of young children includes a 5-year retrospective review of an additional 13 hospitalized patients with accidental isolated spiral tibial fractures.* In addition, we provided nomenclature clarification that described two classes of spiral tibial fractures of children. This discussion delineated the radiologically obscure and more distal fracture of younger children, the Toddler’s fracture, from the childhood accidental spiral tibia1 or CAST fracture (Table 1). FRACNRE RADIOLOGICAL REVIEW Our review of these fractures demonstrated that the location of the fracture was consistently in the distal two thirds of the tibia (Table 2). The distal one-third location was observed for five of the fractures and one fracture (case 4) was located in the distal one fourth of the tibia. The proximal portion of the spiral fracture consistently began laterally (closest to the fibula) and extended distally and medially. Only one patient’s fracture ran opposite in direction. Patient five, who fell while hanging from playground equipment, demonstrated a spiral fracture that began proximally on the medial tibia and extended distally and laterally toward the fibula. Fracture displacement and angulation was consistently minimal. There were no observable differences between the accidental fractures and the fractures of cases 12 and 13 which were judged the result of child maltreatment. The fracture of patient 4 best matched the original description of Toddler’s fractures by Dunbar. It demonstrated no displacement and was located in the distal one fourth of the tibia. However, oblique or additional radiographs were not needed to detect its presence. DISCUSSION In the past spiral tibial fractures of a child’s long bones have been considered by pediatricians and social workers to be strongly suggestive (although nonspecific evidence) of child abuse.’ In this article and an earlier one we present
Presenting Complaint Radiological Obscurity
The spiral fracture is usually found in the distal two thirds of the child’s tibia. There are no associated fractures. The presence of an associated fibula fracture suggests a different mechanism and a greater injury force. The age range is from approximately 2 years to 6 years of age. There is overlap with the Toddler’s fracture which is seen between 9 months and 3 years of age. The fracture occurs most frequently following a fail. A torque or rotational force on the lower extremity appears to be a necessary injury component. Refusal to ambulate or bear weight, an observed limp, minimal pretibial soft tissue edema, discomfort when a rotational force is applied to the lower extremity, and tenderness to palpation over the fracture are frequent physical findings. Limping or failure to bear weight on the injured extremity is the most common presenting complaint. CAST fractures are easily visualized on radiograph. The radiographically obscure Toddler’s fracture is a CAST fracture subset that may require additional studies to establish diagnosis.
additional evidence that isolated spiral tibia1 fractures of children are more commonly the consequence of an accident. Interestingly, the description of the circumstances surrounding the injury is often vague and can cause increased suspicions toward the child’s caretakers. In our previous article we presented new nomenclature with information that described two different presentations of spiral tibial fractures. The recently defined childhood accidental spiral tibial (CAST) fracture is similar but distinctly different from the original definition of the Toddler’s fracture. The Toddler’s fracture was defined as a radiologically obscure, distal third spiral fracture of the tibia occurring in children between 9 months and 3 years.’ The obscurity of the fracture was emphasized and characterized as needing oblique or subsequent radiological studies to clarify its existence. With common orthopedic use of the term Toddler’s fracture, its definition has broadened beyond its original definition to include fractures with characteristics of the recently described CAST fractures.* The CAST fracture, an isolated spiral tibial fracture, is not radiologically obscure and, frequently, begins more proximally (at the middle rather than distal third of the tibia). Additionally, this fracture occurs commonly to children who would not be considered chronologic toddlers (Table 2). In reality, the Toddler’s fracture is probably best considered a subset of the more common CAST fracture. Physiological and anatomical differences of bone related to growth and development may explain these differences in roentgenographic presentation. The periosteum of younger children is much stronger and thicker. This strength allows it
MELLICK AND REESOR n SPIRAL TIBIAL FRACTURES
TABLE2. Spiral Tibia1 Fractures Case
Accidental Fractures 1. 36 mo 2. 21 mo 3. 24 mo 4. 29 mo 5. 39 mo 6. 40 mo 7. 34 mo 6. 44 mo 9. 24 mo Nonaccidental Fractures 10. 9mo 11. 2mo 12. 19mo 13. 17mo
F M M
M-D M-D M-D D1/4 M-D M-D D M-D D
(L) (RI (L)
04 (RI (L) 04 (R) (RI
slipped while jumping on his supine father unwitnessed injury twisted and fell in kitchen running and slipped on a freshly mopped floor fell while hanging from playground equipment stepped off curb and twisted ankle, wearing brother’s boots pushed off picnic table running during temper tantrum, slipped on cover of comic book fell from weight bench in lanai
D P D D
S-J (RI (RI u-1
leg twisted by caretaker “slipped off lap” fell from bed while playing with brother “tripped over dog chain”
ABBREVIATIONS: M, male; F, female; P, proximal; M, middle; D, distal thirds; R, right; L, left leg. NOTE.In all fractures except case 5 the proximal spiral began laterally (next to the fibula) and ended on the distal medial tibia. Patient five’s fracture began on the medial tibia and ended closest to the fibula.
to function as a sturdy envelope that prevents damage to the growth plate and bone. In addition, it splints and minimizes the displacement of fracture fragments. Finally, the bone of younger children is known to be woven bone, which tends to bend or wrinkle rather than shatter.’ One might speculate that the more distal location and radiographic obscurity of Toddler’s fractures is related to the periosteal and bone characteristics of the younger child. The mechanisms of fracture appears to include two general patterns. First, they may occur when the foot is relatively immobilized and a rotational force is applied to the lower extremity. Secondly, the history frequently includes a direct vertical tibial impact, which occurs when the child drops or jumps from a seemingly negligible distance. In our series there seemed to exist a final rotational force due to the injured extremity positioning under the body of the falling child. Gait disturbances or failure to bear weight are often the presenting complaint. Our observations support those of Singer and Towbin. Consequently, we again emphasize the place of spiral tibial fractures in the differential diagnosis for pediatric gait disturbances. The majority of patients with these fractures are not the result of child abuse or neglect. Isolated spiral tibiaI fractures are much more commonly accidental in mechanism. In the 5-year retrospective review of child maltreatment cases only three cases of spiral tibia1 fracture were identified. Furthermore, our review of these cases would suggest that the mystique of spiral long bone fractures may potentially influence the decisions of those teams which decide the possible guilt or innocence of parents. The “nature of the fracture” is not an appropriate basis for confirming child abuse. It seems clear that nonaccidental spiral tibia1 fractures or child abuse
cannot and should not be diagnosed without additional historical or physical documentation of patient mistreatment. Because of the significant social implications associated with a blanket assumption that all spiral tibial fractures are the result of child abuse, we recommend greater recognition that the childhood tibia is one long bone vulnerable to accidental spiral fracture. Nevertheless, we must temper our previous statements with the reminder that evidence is presented in this and previous references’*‘* that confirms the association of child abuse with isolated spiral tibial fractures. Isolated spiral tibial fractures resulting from nonaccidental trauma are best labeled as nonaccidental spiral tibial fractures. REFERENCES 1. Dunbar JW, Owen HF, Nogrady MB, et al: Obscure tibia1 fractures of infants-The toddler’s fracture. J Can Assoc Radio1 1964;15:136-144 2. Mellick LB, Reesor K, Demers D, et al: Tibia1 fractures of young children. Pediatr Emerg Care 1968;4:97-101 3. Rockwood CA, Wilkins KE, King RE: Fractures in Children (vol 3). Philadelphia, PA, Lippincott, 1984, p 995. 4. Tachdjian MD. Pediatric Orthopedics. Philadelphia, PA, Saunders, 1972, pp 1719-1721 5. Medicolegal decisions: Immunity upheld in child abuse reporting. Am Med News 1988;31:38 6. Singer J, Towbin R. Occult fractures in the production of gait disturbance in childhood. Pediatrics 1979;64:192-196 7. Leonidas JC. Skeletal trauma in the child abuse syndrome. Pediatr Ann 1983;12:875-881 8. Hilton SW, Edwards D, Hilton JW. Practical Pediatric Radiology. Philadelphia, PA, Saunders, 1984, pp 453-454 9. King J, Diefendorf D, Apthorp J, et al: Analysis of 429 fractures in 189 battered children. J Pediatr Orthop 1988;8:585-589 10. Merten DF, Radkowski MA, Leonidas JC. The abused child: A radiological reappraisal. Radiology 1983;146:377-381