A FRACTURE IN AN INFANT
History
Bobby is a 13-week-old baby brought to the A&E department one evening by his parents because he is not moving his left leg. They both report that he seemed fine during his bath the previous evening and went to bed as usual. He was awake on and off during the evening, but with a recent cold has been more difficult to settle. They share the baby’s care and last night it was his father’s turn, but he is adamant that he noticed nothing untoward when he fed him and changed his nappy. Bobby’s mother recalls being woken by him crying but is not sure of the time. They both noticed the leg when they woke up this morning. Bobby’s mother wanted to bring him in straight away but his father persuaded her that it was probably the way he had slept and that they should wait a while. Bobby was born at 37 weeks. He was in good condition at birth and they have no concerns about his development. He has been bottle-fed from birth and is often difficult to feed, with quite severe symptoms of gastro-oesophageal reflux. The GP has prescribed Gaviscon but without much improvement. He is on no other regular medication. No diseases run in the family. His father is aged 19 and his mother is 18. They recently moved from a more rural area in the hope of finding employment but with no success yet. Neither of them has any family locally nor has anyone else taken care of Bobby in the past couple of days. They are living in a two-room flat and the baby sleeps in a cot in their bedroom.
Examination
Bobby is a healthy, well-grown baby. The parent-held record shows that he has been gaining weight along the 9th centile. His length is on the 25th centile, as is his head circumference. The only abnormality is that he is not moving his left leg and cries in pain when it is moved. There is soft tissue swelling overlying the left femur. His temperature is 37.7C and he is a bit coryzal. His sclerae are normal.
INVESTIGATIONS
An X-ray of Bobby’s left leg is shown in Figure 89.1.
Questions
• What does the X-ray show?
• What are the worrying features in the history?
• What other investigations must he have? • Outline the management
Medicine
The X-ray shows a mid-shaft spiral fracture of the left femur. The majority of childhood fractures are accidental with an explanation that fits the injury. However, non-accidental injury (NAI) must always be considered and there are certain patterns of presentation and findings that ring alarm bells. The child’s age and mobility are very important factors. The fracture site and type are also important. Metaphyseal and posterior rib fractures are very suspicious and a spiral fracture suggests a twisting injury – unlikely in a non-weight-bearing infant. So the most worrying features in this history are an unexplained spiral long bone fracture in an infant who is immobile and under constant adult supervision. There has also been a delay in reporting the injury. All of these are features that make any injury more likely to be non-accidental. Others include:
• a history that is not consistent with the injury
• a history that changes with time
• inappropriate reaction(s) of carer(s) – vague, elusive or aggressive
• history of a suspicious injury or NAI in child and/or siblings. Any infant with suspected NAI must have a full skeletal survey with an expert radi ology assessment because not all fractures are detectable clinically. Rib fractures may be inconspicuous initially and a bone scan and/or a repeat chest X-ray may also be needed. These investigations should also help exclude the rare differential of osteogenesis imperfecta. He should also have a brain CT scan to exclude injuries such as a subdural haemorrhage. If there is bruising, a full blood count and a clotting screen are necessary.
Steps in management
• Admit to manage the fracture and as a place of safety
• Pain relief and immobilization in traction
• Check the child protection register
• Document, date and sign the history, examination and investigations
• Inform a senior paediatrician, who will confirm the findings and explain openly and non-judgmentally why there are concerns, what is going to happen next and who will be involved
• Refer immediately to Social Care. Where appropriate, they will involve the police
• Attend the multidisciplinary child protection conference to which the parents are invited. Information is shared between all professional groups. Outcomes are the decision of the conference, not of individuals. The aim is always to act in the child’s best interest.
This family have other risk factors for NAI. They are young, have no local support, and there have been difficulties with feeding. The father admitted to losing his temper in the middle of the night after neighbours complained about the crying. He wrenched the baby’s leg trying to get it out of his sleep suit.
KEY POINTS
• The possibility of non-accidental injury should be considered in any childhood fracture.
• Thorough documentation is vital in all possible cases of non-accidental injury.
• Communication between all professional groups is essential in deciding the outcome for the child and family.
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