Case 74

A 7-week-old baby boy presented to the emergency department with a 1-day history of swelling of his right thigh. His father stated that he was holding the baby and bent forward to pick up a dropped bottle and may have injured the baby at that time. He denied any other history of trauma and stated that there were no other complaints. On his physical examination, he had swelling and limited range of movement of his right thigh. He was noticed to be in pain. He had multiple bruises noticed on his right cheek, right palm, right wrist, right forearm, as well as on his scrotum. His bruises are shown in Images 74a–74c. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig74a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig74b.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig74c.jpg"/>

What is your major concern in regards to the bruises and thigh swelling?

How would you further evaluate this patient?

168

Bruises are rare in infants and their presence in this baby should lead to the consideration of abuse or an illness as a cause. ¹ The presence of the swelling and limited movement of his right thigh warranted an x-ray of his right leg, which showed a comminuted spiral fracture involving the mid-diaphysis of the right femur with 10 mm medial angulation of the dorsal fracture fragment. No callus formation was visualized, implying an acute fracture. In the presence of multiple bruises in an infant along with a fracture with no history to explain the injuries, our major concern was physical abuse. It is important when examining babies to perform a careful head-to-toe skin exam in order to be able to detect the presence of bruises and suspect physical abuse in order not to miss the opportunity of diagnosis and have the baby present later with more severe injuries. ²

This baby was evaluated with a skeletal survey that showed a nondisplaced fracture at the mid-portion of the left clavicle with exuberant callus formation. It also showed multiple non-displaced lateral rib fractures involving the right eighth and ninth ribs and left seventh through ninth ribs. No callus formation was seen. He had a complete blood count, prothrombin time (PT) and partial thromboplastin time (PTT) done as well as liver and pancreatic enzymes. His liver enzymes were elevated and an abdominal CT scan was done which was normal. His head MRI scan was also normal. A diagnosis of physical abuse was made and he was placed in a Pavlik harness and discharged home with his grandmother.