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Tibial torus and toddler's fractures misdiagnosed as transient synovitis: a case series
© Seyahi et al; licensee BioMed Central Ltd. 2011
Received: 2 February 2011
Accepted: 13 July 2011
Published: 13 July 2011
The high incidence of transient synovitis in early childhood makes it the first suspected pathology in a limping child. Trauma, which has long been regarded as a causative factor for transient synovitis, may be underestimated in a non-cooperative toddler.
After excluding most serious conditions, such as septic arthritis, a speculative diagnosis of transient synovitis can be made, and this can easily mask a subtle musculoskeletal injury.
We report the cases of three Caucasian patients (two boys, aged 20-months- and three-years-old, and one girl, aged two-years-old), with tibial torus and toddler's fractures which were late-diagnosed due to an initial misdiagnosis of transient synovitis of the hip.
In a non-cooperative child musculoskeletal trauma can be mistaken as a simple causative factor for transient synovitis of the hip and this can easily prevent further investigation for a possible subtle musculoskeletal injury of the lower extremities.
Our experience with the presented cases suggests the need to be more vigilant in the differential diagnosis of transient synovitis in young children.
Toddler's fracture is a subtle, non-displaced fracture of the tibia in children, aged between nine-months-old to three-years-old. The child presents with an acute onset of limp or refusal to bear weight on the leg. Toddlers may be unable to localize pain or give a history. They are also usually uncooperative during the physical exam. Clinical signs of a toddler's fracture can be subtle with non-specific physical findings of local injury.
Transient synovitis (TS) of the hip is one of the most common causes of hip pain and limping during early childhood [1–4]. This benign condition is a clinical diagnosis, which is confirmed by excluding potentially more severe disorders, such as septic arthritis, osteomyelitis, slipped femoral epiphysis and Perthes' disease. Septic arthritis is the first, and occasionally the main condition that most clinicians would like to exclude, due to its devastating course [5, 6]. However trauma, which has commonly been mentioned as a causative factor, has probably been underestimated in the differential diagnosis of this frequent entity [3, 4, 7–11].
We describe three cases of tibial torus and toddler's fractures. The initial misdiagnosis of TS of the hip delayed the true diagnosis.
A two-year-old Caucasian girl presented to our emergency room with acute right-sided lower extremity pain and limping. She had stumbled the same morning she was admitted, and her parents noticed her limping late in the afternoon. She was initially evaluated by the emergency room physician and then consulted by a pediatrician in attendance. She held her hip in flexion and no local tenderness was observed. On physical examination, she had a generalized pain which referred to the entire lower extremity and abduction and internal rotation of the hip was limited. She had a slight fever of 37.4°C, her CRP was negative (1.6 mg/L) and her ESR was 8 mm/hour. With the initial diagnosis of TS, she was given an anti-inflammatory (ibuprofen, 100 mg orally, three times a day) and bed rest was advised.
Toddler's fracture was described by Dunbar in 1964 as a subtle, non-displaced fracture of the tibia in children, nine months to three years of age . The child presents with an acute onset of limp or refusal to bear weight on the leg. Toddlers are unsteady and they may fall with a twist, or they may have gotten their foot caught and fallen. The fall is generally unwitnessed by the parents who will be unsure of an injury. 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 the presented cases. The fracture may only be seen on the oblique views.
Differential diagnosis of acute hip pain and limp
• Septic arthritis
• Perthes disease
• Juvenile rheumatoid arthritis
• Psoas abscess
• Stress fracture
• Overuse syndrome
• Rheumatic fever
• Proximal femoral osteomyelitis
• Kawasaki syndrome
• Gaucher disease
• Tumor (Ewing, osteoid osteoma, osteogenic sarcoma, acute lymphocytic leukemia)
• Serum sickness
• Slipped capital femoral epiphysis
The difficulties in taking history and evaluation in a young child, the natural association with trauma, and referred pain are all important factors complicating the differential diagnosis of TS in early childhood. The presented young children with toddler's fractures were unable to localize pain or give a history. They were uncooperative during the physical examination.
Trauma has been commonly mentioned as a causative factor for TS [3, 4, 7–11]. It has been reported to have occurred in, as high as, 17% to 30% of the patients . Local contusion to the hip is thought to set up a self limiting chemical synovitis which resolves as the hematoma is reabsorbed. Trauma history can be considered as a natural preceding condition in TS. This can prevent a thorough investigation for a probable subtle musculoskeletal injury.
While it is difficult to assess the accuracy of published reports on TS, which is obviously an excluding one, the high rates (up to 30%) of trauma history can be due to several missed diagnoses of musculoskeletal injuries.
Finally, we should also mention the probability of the co-existence of TS in the reported cases. While our patients had limited and painful hip rotation at their initial evaluation, it is not clear if this was due to leg pain or an accompanying TS in the hip. Steady relief was observed in their symptoms after immobilization of the leg.
In non-cooperative young children, musculoskeletal trauma can be mistaken as a simple causative factor for TS of the hip which can easily preclude further investigation for a possible subtle musculoskeletal injury of the lower extremities.
Our experience with the presented cases suggests the need to be more vigilant in the differential diagnosis of TS in early childhood. We believe that a detailed history should be taken from the parents and that a musculoskeletal injury should always be considered, even with a minor trauma history.
Written informed consent was obtained from all three patient's parents for publication of these case reports and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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