Grand Rounds

Accidental Leg Injury in an active toddler

Department of Pediatrics, Naples Community Hospital, Florida, USA

Address for Correspondence: Jane Cox, 720 5th Ave S, Suite 201, Naples, FL 34102, USA.

Clinical Problem :
Case: “Barrett was running across the sofa when he took a dive off pretending to be Superman. I managed to catch him by the ankle as he went past. Now he is crying so hard and I am afraid that his leg may be broken,” confides Mrs. Knott. You listen to her concerns and learn that he is a very active toddler.
Barrett is a twenty two month old male child who was brought by his mother to the pediatric emergency department {ED} in a mid-sized south Floridian hospital and seen by a nurse practitioner. Twenty minutes earlier, the child was playing with his sister in the living room of their home and sustained injury to his right leg as his mother attempted to prevent a fall. He is inconsolable and crying loudly from the pain. His mother denies prior injury to the affected extremity, serious illness or hospitalization. Past History - A circumcision was performed after birth and before hospital discharge. He is current on all Advisory Committee on Immunization Practices recommended vaccinations including his first seasonal influenza vaccination. Barrett lives with his mother, father and sister` all are alive and well. The child’s development milestones are age appropriate. On physical examination, the child is well- appearing but in severe pain. He is tearful and uncooperative. His vital signs are stable, with a blood pressure of 101-30 mm Hg, pulse rate of 122 bpm, respiratory rate of 24 breaths per minute, and an oxygen saturation of 100 percent on room air. His temperature is 97.5 º F {36.4 º C}. Heart tones are normal S1 and S2 without murmurs. The respiratory and abdominal exams are normal. Obturator and psoas signs are unremarkable. The lower extremities are well perfused , have intact peripheral pulses and color. There is no obvious deformity to his left lower extremity. The right lower extremity has localized exquisite tenderness in the mid femur. There is no shortening or distortion of the legs. The left thigh is swollen and seems to tremble or jerk. There is no limitation in the range of motion at the hips or knee joints bilaterally. The neurological exam is normal and no lymphadenopathy is noted.

What are the differential diagnoses_? What is treatment plan_?

Discussion :
Bone fracture injury, hip dislocation, and sprains or strains of the knee ligaments are all possible diagnoses to be considered. The femur is the largest and strongest bone and it requires substantial force to fracture. Child abuse is evaluated in any case of high energy trauma. Remain calm and speak in a quiet voice while asking Mrs. Knott to describe what happened to cause the injury. When Barrett was caught by the leg, the femoral shaft twisted, resulting in a spiral fracture. There were no other significant radiographic findings. Compartment syndrome with neurovascular compromise due to local swelling of the thigh muscle is a serious possible complication. Careful assessment to exclude other injuries in the presence of femoral fracture is necessary.

Femur fractures in young children have been treated with spica casting. Intramedullary rods and nails can be used to immediately reduce and internally fixate the displaced fracture. The rods are inserted into the hollow center of the bone and are removed after treatment. In other situations, it is preferable to use specialty plates designed specifically for children to protect the growth plates. Recently, surgeons have designed and implemented use of the Pediloc ™system. Approved in January, 2009, this system accommodates the contours of children’s bones which are different from adult bones. Recovery is less restrictive and Barrett can return to play faster. After surgical intervention, most children will use a wheelchair for a week or less before being allowed to resume full weight bearing to tolerance and normal play activities.

Bone healing is characteristically rapid in toddlers. The nurse practitioner should continue to monitor at a follow-up clinic visits in 2 weeks, 6 weeks, 3 months and 6 months. A radiograph should demonstrate complete healing the femoral fracture at 3 months. Physical therapy is generally not needed in toddlers and young children due to their naturally physical activity.

E-published: May 2010 Vol 7 Issue 5 Art No. 30

References :
  1. Hockenberry M. Wong's essentials of pediatric nursing. St. Louis: Elsevier. 8th ed. 2009: 1112-1117
  2. Keany J. Fracture, femur. Available on website: Accessed on September 11, 2009.
  3. Mioduszewski V. Wolfson Children's Hospital is first in the nation to use new orthopedic implant system designed by orthopediatrics and specifically for children. Available on Accessed on May 6, 2009
  4. Pemberton J. Path breaking plate gets St. Johns county boy walking. Available on website: Accessed on September 23, 2009

Correct Answers :  yes 91%
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