Spiral Femur Fx in toddler

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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!

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.

In a child older than 18 months with no previous history of fracture or other reason to suspect child abuse the rate that are actually child abuse falls dramatically.

In children younger than 18 months with previous fractures ar other suspected the chances of abuse is huge.

Take a REALLY good history with these patients

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Specializes in NICU, PICU, PCVICU and peds oncology.

I agree with all of these comments. But I personally know two outliers, both the children of nurses who ended up with spiral femur fractures from falling on the sofa when their legs slid between the cushion and the arm. Their feet were wedged into the frame and as they fell they twisted until the bone snapped. Witnessed by non-family members both times - freak accidents!

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I agree with all of these comments. But I personally know two outliers, both the children of nurses who ended up with spiral femur fractures from falling on the sofa when their legs slid between the cushion and the arm. Their feet were wedged into the frame and as they fell they twisted until the bone snapped. Witnessed by non-family members both times - freak accidents!

Absolutely, Even in a child who cannot walk there is no guarantee that the fracture is abuse. In fact statistically it is less likely to be abuse than it is to be abuse for all age groups.

Among children less than 12 months old with all types of femur fractures, investigators found abuse rates ranging from 16.7% to 35.2%. Among children 12 months old or greater with femur fractures, abuse rates were lower: from 1.5% - 6.0%. In multiple studies, age less than 12 months, non-ambulatory status, a suspicious history, and the presence of additional injuries were associated with findings of abuse.

BMC Pediatrics | Full text | Prevalence of abuse among young children with femur fractures: a systematic review

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Specializes in Acute Care Pediatrics.

It doesn't feel like statistically that's the case in my line of work. :( I walk out of work feeling like I must be the only person that doesn't beat my kid. :/

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Specializes in Maternal - Child Health.

I appreciate the information shared by posters, especially scottaprn, who have far more experience with fractures in toddlers, and can accurately address the likelihood of various scenarios.

What bothers me most about the story, perhaps because of my natural skepticism of people, is the Dad's claim that he tried to reduce the initial injury himself. That simply doesn't ring true, unless Dad is a physician.

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Specializes in Complex pedi to LTC/SA & now a manager.
I appreciate the information shared by posters, especially scottaprn, who have far more experience with fractures in toddlers, and can accurately address the likelihood of various scenarios.

What bothers me most about the story, perhaps because of my natural skepticism of people, is the Dad's claim that he tried to reduce the initial injury himself. That simply doesn't ring true, unless Dad is a physician.

Agreed what non-medical person would even consider reduction of a dislocation or fracture in a toddler? That's why I thought lay person reduction = spiral fracture regardless of his self-described methodology.

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Specializes in Pedi.
Absolutely, Even in a child who cannot walk there is no guarantee that the fracture is abuse. In fact statistically it is less likely to be abuse than it is to be abuse for all age groups.

BMC Pediatrics | Full text | Prevalence of abuse among young children with femur fractures: a systematic review

Femur fractures are common in young children, especially those who are just learning to walk. Spiral femur fractures not as common. This case warrants a consult from the hospital's Child Protection Team (which, if he was transferred to a larger/pediatric facility they probably have) and a further work-up to assess for non-accidental trauma. When I worked in a pediatric hospital, if abuse was suspected a skeletal survey was done. If multiple healing fractures are noted, there's your red flag. If there's a head injury, Ophtho is also consulted. Retinal hemorrhages = another red flag. The social situation described in the OP does make me think abuse based on my history with abused children... the vast majority of the time, the Mom's boyfriend (who isn't the father of the child) is the perpetrator. Not saying that's statistically true but anecdotally that has certainly been my experience.

I did once have a case of a baby with a femur fracture. Because he was a baby and non-ambulatory, no one could come up with an explanation for how he would have sustained such a fracture. Child Protective Services immediately took custody. Turned out he had Osteogenesis Imperfecta.

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Specializes in Pediatrics.

Rather have an innocent man investigated for abuse and have it non founded than to return a child to their abusier and have them hurt again with worse injuries.

The fact that the "boyfriend" came upon the child and tried to "put it back in" without seeking medical care is a red flag regardless of what type of fx it is.

It is a sketchy story

The child most likely will get a skeletal series done and the child abuse pediatrician would examine the child.

If it was a 1st injury I doubt the child would be removed. Sadly our CPS system is over run with cases and parents get multiple chances before a kid is removed.....but that is another thread another soap box

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I report to CPS all the time and would NEVER report a case like this just because the child had a fracture even if the story sounded half-way reasonable.

A toddler that landed on his feet would absolutely cause this injury.

Let's say for a second that the child is abused.....odd how there are no other injuries or bruises in various stages of healing.

Nope...would not report this. Kids get injured. It happens. Before anyone says "Oh...err on the side of safety!" Has no idea of what these parents get put through and social services is in your business for a long time before they get out. It can also have an impact on someone's career, marriage, etc.

If I have good reason I don't hesitate. A single injury like this? Absolutely not.

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Specializes in Pediatrics.

You would "never" report because the story sounded half-way reasonable?!?!?

Because you are worried about the parents?

Yes, there are rare cases where innocent parents get investigated but more often there are kids being abused multiple times before there is an injury that puts the kid in front of medical providers

The fact that the boyfriend was playing ortho doc and tried to put the leg back in place without seeking medical help is a red flag.

Are you a child abuse specialist?

If you are not then you are not qualified to make that judgement.

Does a child have to be covered with bruises for you to make that call?

Does that only count for abuse in your book?

I have seen enough NAT were there were not any previous bruises and the child ended up near dead from the 1st time

I have seen kids covered in bruises in stages of healing and were taken into custody and turned out to be new onset ITP and immediately CPS returned the children to parents and closed the case in the ED, so in unfounded abuse they will close the case.

I am shocked that you would be more concerned about the parents then the safety of the children

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