CHAPTER 47

Occult Fractures (Injury Not Detected by Radiography)

Introduction/Etiology/Epidemiology

• Occult fractures are difficult-to-diagnose common fractures in a child with extremity pain, disuse, and a history of trauma in which radiographic findings are usually normal.

• Physical examination is very important in this clinical setting.

• Toddler fractures of the lower extremity are common sites of occult fractures. Fractures of the tibial shaft, calcaneus, cuboid, and first metatarsal are most prevalent in this age group.

• The elbow is also a common site for occult fractures.

Signs and Symptoms

• History of trauma

• Extremity pain

• Disuse

• Swelling is sometimes present.

Differential Diagnosis

• Sprain

• Contusion

• Transient synovitis and infection should also be excluded in a child with pain and disuse but normal radiographic findings.

Diagnostic Considerations

• Occult fractures should be suspected when there is concern for abuse and a child is younger than 2 years of age. The assessment includes (but is not limited to) a skeletal survey and a follow-up skeletal survey.

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