Toddler accident (Full Version)

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Alex Brenner PT MPT OCS -> Toddler accident (April 12, 2005 1:46:00 AM)

According to the mother, her 2 year old daughter pulled a ceramic vase off the kitchen table. The vase then landed on the top of the foot. The little girl does not want to walk and will not help with the history. Her mother was in the other room when this happened so she is uncertain of the exact mechanism. On physical exam, she has swelling on the dorsum of the foot and would not let anyone examine her.

What are the findings?

(all images obtained and used with permission)

[IMG]http://img.photobucket.com/albums/v85/brennerak/babyfoot3.jpg[/IMG]

[IMG]http://img.photobucket.com/albums/v85/brennerak/babyfoot2.jpg[/IMG]

[IMG]http://img.photobucket.com/albums/v85/brennerak/babyfoot1.jpg[/IMG]



SJBird55 -> Re: Toddler accident (April 12, 2005 1:56:00 AM)

Little kids are the hardest with all those little partially formed bones.

The distal end of the third and fourth metatarsal may have a slight, nondisplaced fracture (more easily seen in the second image). That's just a guess though.



ehanso -> Re: Toddler accident (April 12, 2005 3:23:00 AM)

I agree with SJB on the difficulty and Dx, I also see some roughness at the base of the 3rd metacarpal. I'll just throw the dice and say "Baby needs new shoes". Oops I forgot there is not supposed to be any gambling here.



UTDC -> Re: Toddler accident (April 12, 2005 12:16:00 PM)

1st cunneiform fracture?

Tough one.



pablo w -> Re: Toddler accident (April 12, 2005 3:49:00 PM)

I agree with SJ, There is a definite fracture at the distal end of the fourth metatarsal, seen best on the second film. There is a fracture line visible along the lateral side just proximal to the joint. I also suspect fractures of the 2nd and 3rd metatarsals at the same level. The base of the 3rd MT looks a little strange, but I am unsure of the significance of this.

Pablo



jma -> Re: Toddler accident (April 12, 2005 5:10:00 PM)

I agree as well.



JLS_PT_OCS -> Re: Toddler accident (April 13, 2005 3:38:00 AM)

Yeah, I see the distal 4th metatarsal that might be a fracture.
I also question the proximal 1st. I don't know how early or late that epiphysis closes, but it seems to have 2 different ossification centers. The rounded appearance makes me think it's not a fracture, though.
Yet another example of how tough peds radiology is, I would never make a call like this without a radiologists opinion.
Good case.
J



fapt -> Re: Toddler accident (April 13, 2005 6:07:00 AM)

According to the X-ray,
I suggest that the little girl has base of the 1st metatarsal bone fx. There are 2 pieces of the frgements.

Can n/e give me the correct answer....lol


Cheers, Lin MS PT, Taiwan



Dr.Wagner -> Re: Toddler accident (April 14, 2005 10:58:00 PM)

My guess is that your instructor is looking for a Salter Harris classification.

And by the way, ANY toddler with a questionable xray who suffered small trauma and now doesn't want to walk, will get a SH classification of I...regardless of the film.



chiroortho -> Re: Toddler accident (April 15, 2005 6:56:00 AM)

All potential pediatric physeal injuries are considered S-H injuries until proven otherwise.

Fractures heal. Growth plates may not, and when they heal badly the results can range from minimal to major deformity. If you've ever seen a Madelung's deformity you understand.



Alex Brenner PT MPT OCS -> Re: Toddler accident (April 15, 2005 9:30:00 AM)

What is a Madelung deformity?



hmgross -> Re: Toddler accident (April 15, 2005 9:51:00 AM)

Isn't is congenital? I believe several yrs. ago I had a girl with this deformity of the wrist.
Check out:
[URL=http://www.emedicine.com/orthoped/topic513.htm]www.emedicine.com/orthoped/topic513.htm[/URL]



chiroortho -> Re: Toddler accident (April 16, 2005 8:25:00 AM)

[QUOTE]Madelung deformity (MD) of the wrist is characterized by a growth disturbance in the volar-ulnar distal radial physis that results in a volar and ulnar tilted distal radial articular surface, volar translation of the hand and wrist, and a dorsally prominent distal ulna.[/QUOTE]The predisposition for this may be congenital, I don't recall, but the issue is the suboptimal physeal growth.



jma -> Re: Toddler accident (April 17, 2005 7:28:00 AM)

Okay then, what is the clinical and radiologic diagnosis?



chiroortho -> Re: Toddler accident (April 17, 2005 9:14:00 AM)

JMA, are you talking about Madelung's deformity? If so, the website that Holly listed above does a good job of answering your question.

Greg



jma -> Re: Toddler accident (April 17, 2005 10:20:00 AM)

I'm sorry, I meant for the x-rays concerning the toddler accident post. The emedicine site explained Madelung's Deformity very well.



Alex Brenner PT MPT OCS -> Re: Toddler accident (April 19, 2005 8:24:00 PM)

I will be gone for one week doing some stuff for the government. I will post the findings next week.



Alex Brenner PT MPT OCS -> Re: Toddler accident (April 25, 2005 8:26:00 PM)

AP, lateral and oblique views of the left foot were obtained.

There is fracture at distal left 2nd, 3rd and 4th metatarsal. The joint
spaces are unremarkable. No other bone fracture seen. No radiopaque foreign
body noted.

IMPRESSION: Fracture at distal left 2nd, 3rd and 4th metatarsal.

[IMG]http://img.photobucket.com/albums/v85/brennerak/babyfoot5.jpg[/IMG]



Jeep -> Re: Toddler accident (April 26, 2005 1:19:00 AM)

Alex-
I haven't been here for a while, and look forward to participating/contributing to future cases. You do an awsome job of posting films. And I thoroughly enjoy the exercise. Thank-you



jbeneciuk -> Re: Toddler accident (April 26, 2005 3:46:00 AM)

does swelling have the capability of "hiding" a fracture ?? if bone is more dense than water, wouldn't a radiograph be able to reveal a fracture line even in the prescence of swelling ??



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