toddler with leg pain

by Divina
(san antonio, texas)

My son is 1 yr 9 months slipped on a clothes hanger and twisted his leg 12 days ago took him to the ER xrays came out OK gave him ibuprofen and that was it took him 3 days later still not walking the Dr examine was fine and xray'ed again everything came out fine ... had a follow up Monday we are waiting on other xrays but my son is still in pain he walks a bit but very slow and with a limb he can be fine at times then all of a sudden he's grabbing at his lower leg crying in pain for several mins. We are giving him his meds, wondering if I should ask for an mri or just let it heel

RESPONSE

Hi Divina,

First of all, stop with all the x-rays. In twelve days your son has had three sets of x-rays. Yes, sometimes a stress fracture may not initially show up on x-ray, but I am wondering why the doctor took a second set of x-rays only three days after the set that was taken in the Emergency Room.

There are a few possible causes of your son's continued pain after twelve days. He may have sustained a soft tissue injury, meaning when he slipped he did some damage to one of the muscles in his lower leg. This would include damage to the tendons as well which is the extension of the muscles. Rest and ibuprofen should have helped this and in an otherwise healthy child he should have been healed by now. The only exception would be if he is very active and has been trying to run around in spite of the injury.

As I just mentioned, there is always the chance that your son sustained a stress fracture of either the tibia (most common) or the fibula bone. Many times a stress fracture will not show up on x-ray, even a follow up x-ray ten to fourteen days later, may still not show signs of the fracture. In these instances then more advanced imaging may be needed such as an MRI.

I do think it may be too early to consider advanced imaging but that is not my decision to make.

The other possibility that may be causing delayed pain in your son's leg is the possibility of damage to the growth plate of the tibia bone. In an effort for bones to continue to grow as the child grows, each bone in the body has a growth plate, or epiphyseal plate from which the bone expands.

The tibia has two growth plates, one at the top part of the bone, close to the knee, while the other is at the other end of the bone closer to the ankle.

The problem here is that when you look at the growth plates on x-ray it can be very difficult to tell the difference between a normal growth plate and one that has a fracture running through it. Fractures through the growth plate are classified according to the Salter-Harris classification. There are five types of fractures through the growth plate.

Epiphyseal fractures that go undetected have the potential to adversely affect the growth plate as your child ages. It may cause an overall shortening of the particular bone; it may also cause the bone to growth slightly angulated.

I am not saying this is what has occurred in your son, but you should have your doctor check for this possibility. If the majority of pain is coming from the area of bone where the growth plate is located then further investigation is necessary. Usually casting the leg for a period of time is all that is necessary to allow the fracture to heal.

Marc Mitnick DPM
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