A subtle oblique or spiral lucency in the distal tibial diaphysis of a limping 1–3-year-old, often seen on only one view — add an internal oblique view, and if still negative, treat and repeat at 7–10 days.
Orient first
- Low-energy twisting injury of an ambulant toddler; the child refuses to bear weight.
- The fibula is intact; a fibular fracture or metaphyseal corner fracture raises non-accidental injury.
- The calcaneus, cuboid and first metatarsal base are other occult sites in this age.
Acquire the study
- AP and lateral tibia and fibula including knee and ankle; internal oblique view; foot radiographs when the tibia is normal.
The manoeuvre
- AP and lateral view: faint oblique or spiral lucency in the distal third of the tibial shaft.
- Internal oblique view: often the only projection that shows it.
- Periosteal reaction on the follow-up radiograph at 7–10 days.
- Fibula, metaphyses (corner fractures) and the foot bones.
- Soft tissue: joint effusion (septic arthritis mimic).
What confirms it
- A spiral or oblique distal tibial lucency, or periosteal new bone at follow-up, in a limping toddler.
What licenses you to exclude it
- Normal initial radiographs do not exclude it; a normal follow-up at 7–10 days does.
The classic misread
- Missing it because only two views were taken.
- Missing a metaphyseal corner fracture that points to non-accidental injury.