Question of the week # 279

279 ) A 14 month-old child is brought by her concerned father to the Emergency department with a history that the child slipped out and fell on the ground from a table that is 10 feet in height. He says the accident occurred last night when he let the child stand on the table. The child cries when the right thigh is touched and does not move the right lower extremity. Rest of the physical examination is normal. There are no suspicious bruises or contusions on the skin. An x-ray of the right femur is shown below.

A skeletal survey is obtained and does not show any other fractures. There are no skull fractures or retinal hemorrhages or neurological deficits.

Based on the x-ray findings and the history, which of the following is the most likely diagnosis?

A) Osteogenesis Imperfecta

B) Fibrous Dysplasia

C) Accidental Injury

D) Child Abuse

E) Pathological Fracture from Ewing Sarcoma

17 Responses

  1. e, soft tissue shadow and massive onion peel periosteal reaction plus dense bone pattern with loss of medulla-cortex fine differentiation

  2. I will go with E.

  3. e

  4. E

  5. Is E, but……..please change the age of the patient. In 11 years as oncologist I have never seen a Ewing at 14 month. I do not said is impossible, but please change the age of the patient.

  6. eee

  7. this is child abuse, not ewings, what we see is, old fracture, healing, forming callus

  8. D) I also think child abuse. Why concerned father did not come immediately when child had fall and serious pain? and The X ray looks like old fracture with callus formation.
    Although leg bone fractures can occur accidentally if a child runs and falls with a twisting motion while the foot remains stationary on the floor, such fractures suggest abuse in the non-ambulatory patient.

    As with skull fractures, rib fractures are of extreme concern. The distal or mid clavicle can be easily injured in an accidental fall, but a fracture of the most medial aspect of the clavicle is particularly worrisome.22 The long bones are commonly injured in an accident, but in a child older than 1 year, the long bones (femur, humerus, tibia, and forearm bones) are also the most common location of non-accidental injury.22

  9. d.
    it is only callus formation and neglected fracture of femur.

  10. looks like spiral fracture
    child abuse

    • Callus in diaphyseal fractures generally forms no earlier than 5 days after a fracture, but will usually form by 14 days.
      Thus, fractures without visible callus may be up to 14 days old, and fractures which demonstrate a little bit of callus are at least 5 days old. Large amounts of callus indicate at least 2 weeks old.
      These signs can be used to correlate with the history. For instance a child that fell out of bed the day before cannot have a fracture with callus formation.
      Metaphyseal fractures do not typically heal with callus as there is no periosteal disruption, so dating of metaphyseal fractures is difficult.
      child abuse.

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