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Indeed, any fracture with an inappropriate history is suspicious. a child with a permanent physical disability or totally dependent child who will never be able to walk, also raises the suspicion of inflicted injury. Bilateral healing fibular fractures in a non-ambulant child, i.e. The finding of bilateral isolated healing fibular fractures in a pre-ambulant 6-month-old infant is suspicious for inflicted injury by virtue of fracture location and multiplicity and patient age and pre-ambulatory status. Multiple long-bone fractures, especially bilateral fractures, are of moderate specificity for abuse. Half of all fractures in infants younger than 12 months old are attributable to physical abuse with the highest incidence at 4 months of age. Ībusive fractures are more common in children younger than 2 years old. Fibular stress fractures result from repetitive injuries, usually in ambulant athletic younger children and adults: It is thought that in toddlers, they result from the novel stresses associated with new/developing ambulation. Stress fractures result from repetitive low-grade forces, each insufficient to cause a fracture but cumulatively weaken both the bone and the overlying muscle, eventually leading to fracture. Given that the fractures of both fibulae occurred at near identical positions with no other acute or healing radiologic or clinical injury identified, it was believed that on the balance of probabilities, this purported mechanism of repeated low-energy impact force was consistent with the injuries sustained.įibular fractures are rarely seen in physical abuse – when they do occur, they result from direct impact to the fibular shaft and typically alongside a tibial fracture - or if undisplaced, they may result from indirect forces as the leg is bent or twisted. A review of the videos by the radiology expert instructed in the matter confirmed that the lateral aspects of the infant’s legs repeatedly hit the metal frame of the playpen over prolonged periods at approximately the same level at which the radiologic abnormalities were identified. They were consistent in providing this explanation and produced several videos to illustrate the mechanism (Fig. Legal proceedings commenced, during the course of which it occurred to the child’s parents that the fractures might have been sustained as a result of repeatedly banging his legs against the metal frame of his playpen. The head computed tomography and ophthalmology examinations were normal. Bone profile and vitamin D (117.3 nmol/L) were normal and did not suggest bone fragility. Radiographic bone modelling and density were normal with no features to indicate an underlying disorder that might predispose the patient to fracture. However, by the time of repeat radiographs 5 weeks later, the right fracture had healed, while the left showed evidence of further interval healing (Fig. A follow-up skeletal survey was not performed. The finding of healing bilateral fibular fractures was reported as unusual, further raising the suspicion of inflicted injury. 3) at an almost identical position to the left fibular fracture. An initial skeletal survey (excluding the left leg) revealed a further healing undisplaced fracture of the right fibular diaphysis (Fig. 2) performed 2 days later because of persistent symptoms demonstrated increased periosteal reaction and the suspicion of inflicted injury was raised. An orthopaedic follow-up radiograph (Fig. The child was well cared for and there were no bruises, scratches or other stigmata of abuse.Īnteroposterior and lateral radiographs of the left leg demonstrated a subtle undisplaced fracture of the left fibula but were initially reported as normal (Fig. There was no history of illicit drug or excessive alcohol use, the family was not previously known to social services, and the boy’s immunisations were up to date. The clinical teams found nothing suspicious in the caregivers’ behaviour or social history. No other concern was reported and there was no relevant medical history of note. His caregivers persistently sought medical attention for the limited use of his left leg: He was presented to the emergency department 3 days later, and again 6 days after his initial presentation to his general practitioner.
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He was given a diagnosis of transient synovitis and discharged home. A 6-month-old boy was presented to his general practitioner after his caregivers noticed that he was not holding or using his left leg in a normal manner.