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Case 127



Veena Ramaiah

Question

A 5-month-old infant presents with right leg swelling. Per the mother, the baby rolled off of the bed while she was in another room. She did not witness the fall but heard a cry. The bed is a box spring and mattress on a frame and the floor surface is hardwood. She cannot recall the position the baby was in when she got to him. There are several caretakers at home including the father and maternal grandmother. Mom reports both were at home; however, they are not present in the emergency room (ER) to interview.

On exam, his vital signs are stable, and he is alert and quiet. He is in no apparent distress until the extremity exam. His head shows no signs of injury and his skin exam has no marks or bruises. His extremity exam shows swelling to the mid-thigh area. He cries and is very tender to palpation of the mid-thigh area and has apparent pain with any range of motion of the leg. He does not cry with palpation of the right foot and lower leg. He cries with flexion of the right knee.An x-ray of his right femur is shown next.

Is this fracture morphology concerning for abuse? Does the history provided adequately explain the fracture seen here?

Answer

Yes, this fracture morphology is concerning for abuse. It is a commonly held misconception that spiral fractures are the most concerning for abuse. However, recent studies have identified that the most common morphology of abusive fractures is transverse.

Ultimately, any fracture morphology can be from

an accidental or abusive manner. The key to determining  which one lies in  the history, the level

of suspicion, and the investigation to corroborate or refute the history given. Non-ambulatory infants are at highest risk of abusive injury, and their injuries often warrant further medical evaluation and child welfare and police investigation. Even when a history is provided, it is not possible to determine the truthfulness of that history oftentimes without an investigation. Many explanations are plausible; however, determining the truth is often beyond the resources of the ER or a clinic.

Due to concerns about the history provided, the patient’s age and developmental level, and the need to corroborate the history, a report was made to police and child welfare for an investigation. While in the ER, the child underwent a skeletal survey, head CT, and trauma labs. The skeletal survey revealed three healing rib fractures to the posterior right ribs. On further investigation, it was discovered that his mother was home alone with the baby. There were no other adults present as originally reported. In addition, there was no prior history of trauma to explain the rib fractures. In spite of an in- depth investigation, no other history was obtained to explain the femur fracture; however, the rib fractures remained unexplained. There was not enough evidence for criminal charges; however, child welfare indicted the mother for abusive injury and the child was placed in a safe environment while the mother underwent services and intervention.

Keywords: extremity injury, child abuse, orthopedics

Bibliography

Murphy R, Kelly DM, Moisan A, Thompson NB  et al. Transverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures are. J Bone Joint Surg January 2015;97(2):106–11.

Pierce MC, Bertocci GE, Janosky JE, Aguel F et al. Femur fractures resulting from stair falls among children: An injury plausibility model. Pediatrics June 2005;115(6):1712–22.

Scherl SA, Miller L, Lively N, Russinoff S et al. Accidental and non-accidental femur fractures in children. Clin Orthop Relat Res July 2000;376:96– 105.


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