Question of the week # 278

278) A 34 year old mother brings her 18 month old child to the emergency room. She is in tears and reports that the child was playing on the sofa and has fallen down 1 day ago landing on his left foot and since then has not been moving his left lower extremity. The child is crying incessantly. Physical examination reveals tenderness and swelling in the left mid-thigh. An x-ray of the left lower extremity shows a non-displaced hair line fracture of the femur shaft and the fracture age consistent with reported history of time of injury. Which of the following is the most appropriate next step in management?

A) Contact Child Protection Services

B) Skeletal Survey

C) Open reduction and internal fixation

D) Bone scan

E) CT head

7 Responses

  1. E………
    Child abuse or non-accidental trauma is a clinical diagnosis. It is the constellation of history, physical examination, radiographic evaluation, laboratory testing and investigation that determines if child abuse has occurred.
    Fractures can be a presenting symptom of abuse but they are also common problems not associated with abuse.
    Femoral shaft fractures are estimated to account for only 1.6% of all fractures in children, therefore they are potentially more suspicous for child abuse.
    There is no particular pattern of femur fractures that is pathognomonic for child abuse, therefore all femur fractures could be suspicious. Several early studies found spiral fractures to be the most common fracture type, therefore many clinicians may still believe that spiral fracture are indicative of abuse. Spiral fractures may be caused by other mechanisms.
    More recent reports, show transverse fractures to be most common overall and more common in child abuse. Therefore clinicians should consider abuse potentially in any child with a femur fracture and in particular with transverse fractures which may be overlooked.

    So, others good question will be…..

    1. What other body locations could be concerning for child abuse?
    2. What laboratory evaluation should be done during an investigation for possible child abuse?

    3. At what ages should a head computed tomography be considered as part of the investigation for possible child abuse?
    4. Which fractures are considered radiographically pathognomic for child abuse?

    But always the first concern in child abuse is head trauma and any tipe of intracraneal hemorrhage. Always do CT head to rule out this.

  2. eee

  3. E As explained above . Thank you for explanation, btw.

  4. B

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