From the Guidelines
The most appropriate next step in management for this 9-month-old boy with a spiral femur fracture is notification of child protective services (option A). This recommendation is based on the concerning nature of the injury in relation to the child's developmental stage and the reported mechanism. At 9 months of age, most infants are not yet walking independently, making the explanation of slipping on a wet floor inconsistent with the child's expected capabilities. Additionally, spiral fractures in non-ambulatory infants are highly suspicious for non-accidental trauma, as they typically result from twisting forces applied to the limb 1. While medical evaluation and treatment of the fracture is essential, the discrepancy between the reported mechanism and the injury pattern necessitates involvement of child protective services to ensure the child's safety and to investigate the circumstances surrounding the injury. Other tests like calcium levels, CBC, bone scan, or CT scan may be appropriate for further medical management but are not the most urgent next step given the concerning social circumstances. The American Academy of Pediatrics emphasizes the importance of a comprehensive physical examination and careful review of the growth chart to identify any signs of neglect or underlying medical conditions that may contribute to bone fragility 1. However, the primary concern in this case is the potential for non-accidental trauma, and therefore, notification of child protective services takes precedence over other diagnostic tests or medical interventions. It is also worth noting that the equipment and supplies necessary for basic life support and advanced life support ground ambulances, as outlined in the joint position statement by the National Association of EMS Physicians and the American Academy of Pediatrics, do not directly address the specific concern of non-accidental trauma in this scenario 1. Therefore, the focus should remain on ensuring the child's safety and investigating the circumstances surrounding the injury, rather than solely on medical management of the fracture.
From the Research
Next Steps in Management
The most appropriate next step in management for a 9-month-old boy with a spiral fracture of the femur is:
- Notification of child protective services, as spiral fractures in non-ambulatory children are highly suggestive of non-accidental trauma 2
- A thorough history and physical exam is critical to identifying abuse, and standardized screening tools as well as clinical pathways can assist with identifying patients who may have an injury secondary to abuse 3
- The interpretation of medical results by healthcare professionals can be influenced by contextual information, and it is essential to prevent contextual influence as much as possible 4
Considerations
- Femur fractures in infants should constitute a red flag to a pediatrician, and it is crucial to recognize, record, investigate, and potentially result in measures to protect the child 5
- A history suspicious for abuse, physical or radiographic evidence of prior injury, and age younger than 18 months are risk factors for abuse 2
- Clinicians can use a predictive model to guide judgment and referral to social services when seeing femur fractures in very young children in the emergency room 2
Diagnostic Approach
- A skeletal survey should be performed in all cases of suspected child abuse, and a complete workup per the clinical pathway is essential 3
- The reported mechanism of trauma could negatively influence the physician's appropriate and unbiased judgment, and it is crucial to consider the biomechanical mechanisms of femur fractures in infants 5