Case Author(s): David A. Hillier, M.D., Ph.D. and Barry A. Siegel, M.D. , 6/28/99 . Rating: #D2, #Q3

Diagnosis: Toddler's fracture

Brief history:

18-month-old boy with a limp.


Bone scintigraphy

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View second image(xr). Radiographs of right tibia

Full history/Diagnosis is available below

Diagnosis: Toddler's fracture

Full history:

18-month-old boy, who sustained a twisting injury to the right leg while sliding 7 days ago and who now refuses to bear weight on the right leg.


Bone scintigraphy, 3.7 mCi Tc-99m methylene diphosphonate (MDP)


1. Bone scintigraphy (2/26/98):

- Anterior radionuclide angiogram and immediate static image reveal mild hyperperfusion and somewhat greater hyperemia in the region of the entire right tibial shaft.

- Anterior and right and left frog-leg lateral delayed images show moderately increased uptake in the right tibia (except the proximal metaphyseal region)

2. Right leg radiographs (five days earlier):

- Normal


Usually, a spiral fracture can be diagnosed clinically. In equivocal or atypical cases, bone scintigraphy may be helpful. Toddler’s fracture, usually seen in the 1 to 3-year-old age group, results from a torsional motion of the lower extremity. The patients generally present with limping, refusal to bear weight on the affected side, tenderness and warmth. They are treated with a long-leg cast for approximately 6 weeks.

If radiographs in a case of suspected toddler’s fracture are negative, a cast will commonly be placed for 7 to 10 days. This is then removed and a new radiograph is obtained. This will usually reveal the fracture or periosteal reaction if there has been a spiral fracture.

If there is a concomitant fever, leukocytosis or other reason to suspect an inflammatory process, bone scintigraphy should be considered. The uptake pattern in toddler's fracture will typically reveal a linear, spiral band of increased activity or more diffuse uptake that is centered in the mid diaphysis, as in this case (Miller and Sanderson, 1998).

Bonfield W, Grynpas M. Spiral fracture of cortical bone. Biomechanics. 15, 555-559. 1982.

Chao S, et al. A mechanism of spiral fracture of the humerus: a report of 129 cases following the throwing of hand grenades. J Trauma. 7, 602-605. 1971.

Hieilbronner D, et al. Fractures of the humerus in arm wrestlers. Clin Orthop and Related Res.149, 169-171. 1980.

Miller J, Sanderson R. Scintigraphy of toddler’s fracture. J Nucl Med. 29, 2001-2003. 1998.

Differential Diagnosis List

There is diffuse increased uptake in the right tibia. The degree of uptake in the mid diaphysis is of equal or slightly increased degree than the remainder of the bone. The most likely diagnosis with this pattern of uptake is a spiral fracture (toddler’s fracture). Osteomyelitis will usually produce more focal abnormalities and is usually located in the metadiaphyseal region. Similarly, tumors are generally more focal.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Effect of Trauma)

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Case number: bs104

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