Case 25

A 5-week-old baby girl presented with irritability for approximately 6 hours prior to presentation. Her parents also noted swelling of her right thigh within the previous hour. Her parents denied any history of trauma and she was otherwise asymptomatic and feeding well. On her initial physical examination, the infant was noted to have a swollen and tender right thigh. She also had bruises on her forearms bilaterally (Image 25a). A chest x-ray was also obtained (Image 25b). https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig25a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig25b.jpg"/>

What findings do you see on her first x-ray?

Would additional imaging help?

How would you further evaluate this infant?

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An x-ray of the right thigh showed a spiral fracture of the midshaft of the right femur. There was also a healing fracture with callus formation of the mid-left clavicle seen on the initial bone survey. No other fractures were seen.

Oblique or ‘rib’ views can be better at showing posterolateral lesions, particularly on the right (arrows, Image 25c). These views should be considered as a routine part of a skeletal survey to evaluate for occult child abuse.

This infant should be evaluated for child abuse. She had an initial skeletal survey in addition to head imaging and a dilated retinal exam. She also had a complete blood count and liver enzymes drawn. As a follow-up, she had a bone survey obtained approximately 2 weeks after the initial bone survey. It showed six additional fractures (arrows point to three of these). It demonstrated the healing displaced fracture of the midshaft of the right femur and the healing fracture of the left mid-clavicle. In addition it showed healing fractures of the anterolateral aspect of the right fourth and fifth ribs, healing fractures of the bilateral distal tibiae and healing fractures of the bilateral distal humeri. This case stresses the importance of a follow-up bone survey in suspected cases of child abuse, especially in children under the age of 2 years. ¹ Fractures can be difficult to identify on an initial physical examination, prompting the need for skeletal surveys in younger, particularly preverbal, children. ² The American Academy of Pediatrics (AAP) recommends that a skeletal survey be completed for any child aged 2 years or younger who is suspected of being a victim of physical abuse. However, initial surveys may not reveal all fractures. Therefore, a follow-up survey is recommended approximately 2 weeks following the initial survey.