A 6-month-old girl is brought to the emergency department (ED) because of persistent crying for the past 6 hours. Her teenage father informs you that she has been inconsolable since waking from her nap. No recent illness, trauma, fever, or other complaints are reported. On physical examination the patient is alert, awake, and crying. You note swelling, deformity, and tenderness of the left femur. When inquired about this finding, the caretaker responds, “Her leg got stuck between the rails of her crib.” You obtain the radiograph as seen in the following figure. Which of the following is the next best step in management?
(Courtesy of Ethan S. Wiener, MD.)
a. Genetic workup for osteogenesis imperfecta and other bone abnormalities
b. Orthopedic consultation for closed reduction
c. Serum electrolytes including calcium and phosphate
d. Perform skeletal survey and contact Child Protective Services
e. Placement of posterior splint and discharge home with orthopedic follow-up
The answer is d. This is a case where nonaccidental trauma (NAT) should be considered. This is a classic example of a “bucket handle” fracture. Metaphyseal corner fractures, known as bucket handle fractures, are considered pathognomonic for abuse and are caused by rapid shearing forces or twisting motion. Spiral fractures in a nonambulating child, fractures of the posterior ribs, sternum, scapula or spinous processes may be the only presentation of child abuse; multiple fractures in various stages of healing are also highly indicative of abuse. Any type of trauma that does not fit the mechanism should raise suspicion and alert the physician of the possibility of abuse. In this case, the fracture pattern mandates further workup for NAT. According to the American Academy of Pediatrics (AAP), the skeletal survey is the initial test of choice for all children suspected of being abused. Additional workup may be indicated based on the age and presentation of the child. In this case, a head CT scan and ophthalmology consultation should also be strongly considered. All states have mandatory reporting of child abuse. It is also mandatory to contact the local Child Protective Services to further investigate the situation.
Osteogenesis imperfecta (a) is a rare genetic condition caused by mutations of the type I procollagen gene. Children may present with fractures in the setting of little or no trauma. Classic blue sclerae may be present. This type of injury should not be simply splinted and discharged home (e). A simple posterior long leg splint may be adequate treatment for this fracture at this time but not for the overall disposition. Orthopedic surgery (b) should be included early in the intervention, but their expertise is not necessarily critical in ...