Spiral Femur Fx in toddler

[lahryn18]

Because of the obvious HIPPA reasons and sensitivity of this case, my post might be pretty vague and/or short. Details I could change, I did. Apologies! Anyway, I recently had a toddler come to the ED with a chief complaint of a "possible broken or dislocated femur". The injury was apparently caused from jumping off the bed approximately 3' off the ground. The injury was not witnessed by mom or mom's boyfriend. When explaining what happened the boyfriend said he was outside when he heard the crying. He said he attempted to "pop it back into place" immediately upon seeing them. Although, what he described as "popping it back in" was not the best idea. One hand was placed on the outside of the leg slightly above the knee and the other hand was placed on the inside of the leg slightly below the groin and at the same time pushed. They said they heard a pop and then immediately brought the kid in. After viewing the X-rays we find out the pt has a complete spiral fracture of the femur. In school they tend to pound into your head the idea that a spiral fracture in small children is a really good indicator for abuse. I think that's were my bias is coming from. I know it's possible for any bones of a child's to be broken in any way and it truly isn't abuse. I'm not too experienced in pediatric care and have only dealt with a few peds abuse cases. That's why I wanted to ask you all for your opinions/insight on this topic. I'd hate to think an innocent man could receive punishment for legit accident but I'd also hate to send the of home with someone who will abuse them again. Very interested to hear your thoughts! Thanks so much!

[Purple_roses]

I don't know if we can really help you with this. We don't have all the information and this is potentially a very big issue. I would seek out advice on this matter from a more reputable source.

[Rose_Queen, BSN, MSN, RN]

Remember that nurses are usually considered mandated reporters. However, as we are not there and able to see the full history and assessment, you should seek guidance from your manager, a senior nurse, risk management, or someone else at your facility to assist you in how to proceed.

[lahryn18]

Oh yes, it was reported and that part of the case was handled. I wish I knew the outcome of it but since this patient was transferred to a larger facility, their social workers/case managers took over at time of transfer. I was more just wondering if it's common to have such an injury truly by accident? Luckily all I had to do was initiate the process by reporting to child protective services because I can only imagine how hard it is to investigate things like this.

[JustBeachyNurse, LPN]

It's possible the fracture occurred when he tried to "replace" the femur. It's rare but not often from a fall. Has to be a twisting motion to spiral such as foot get stuck as spinning or twisting.

It's not your job to determine mechanism of injury just yo report atypical or concerning injuries.

[scottaprn]

Spiral fractures of the femur are a definite red flag for abuse in a child that is too young to walk. This makes sense because they can't create the torsion necessary to create that fracture pattern.

In children that are able to walk it is much less likely to be child abuse. A fall from that height is very possible to create a spiral femur fracture. That is why they are called toddler's fractures.

were there other signs of abuse like previous fractures, bruising etc?

[scottaprn]

It's possible the fracture occurred when he tried to "replace" the femur. It's rare but not often from a fall. Has to be a twisting motion to spiral such as foot get stuck as spinning or twisting.

It's not your job to determine mechanism of injury just yo report atypical or concerning injuries.

A spiral fracture would be almost impossible based on the description of how the parents tried to "relocate" it. Transverse fracture would be much more likely.

Children don't have a developed proprioceptive system when they fall so very often there foot gets stuck when they fall and their body rotates around it.

If there are no other signs of abuse, no previous fractures and the child is over 18 months old the chances of it being a fracture from abuse is very low.

[lahryn18]

A spiral fracture would be almost impossible based on the description of how the parents tried to "relocate" it. Transverse fracture would be much more likely.

Children don't have a developed proprioceptive system when they fall so very often there foot gets stuck when they fall and their body rotates around it.

If there are no other signs of abuse, no previous fractures and the child is over 18 months old the chances of it being a fracture from abuse is very low.

If the foot did get stuck, wouldn't that more likely cause a spiral tib/fib fracture instead of one in the femur?

[JustBeachyNurse, LPN]

If the foot did get stuck, wouldn't that more likely cause a spiral tib/fib fracture instead of one in the femur?

It depends on where the twisting motion occurred.

[scottaprn]

If the foot did get stuck, wouldn't that more likely cause a spiral tib/fib fracture instead of one in the femur?

It depends on the forces of the injury and the bone strength. A femur is more likely given the fall from height. Femur fracture in pediatrics also have peaks at a young age from injuries like described above and then again in the teenage years due to accidents and risk taking that teens are famous for.

[xoemmylouox, ASN, RN]

If there is ever a chance I report it. It isn't my job to play detective and decide who is honest and who isn't. If something is off I call it in - regardless of what my employer or the physican thinks. I won't have a child suffer because I wasn't sure and didn't speak up. People can do unimagineable things to children and get away with it for years. Accidents happen, but more often than not it's more than that.

[~PedsRN~, BSN, RN]

Any child under the age of three that comes in with ANY broken bone is flagged in my facility. This child in particular would be flagged as a Non Accidental Trauma, a sitter placed in the room, and a series would be done to check for other previous breaks. I will say that the majority of spiral fractures I have ever seen have been the result of non accidental trauma.