You are the orthopaedic registrar on call. You are called to the emergency department to see a 4-month-old child with a displaced midshaft diaphyseal femoral fracture who has been brought to hospital by his mother because he is distressed and inconsolable. The given history is that he may have rolled off the bed onto the floor 2 days previously.

1.  How would you manage this patient and family in the emergency department?

 I would take the history from the mother, examine the child and record both carefully. There are a number of concerning features about this presentation. A femoral fracture in a non-ambulatory child would alert me to the possibility of a non- accidental injury. The delay in presentation is also concerning. I would also look to corroborate the history from any other family members attending.

  I would be looking for any other sign of injury to the child, evidence of neglect and a normal interaction between mother and child. I would also consider the possibility of a skeletal dysplasia as a cause of bone fragility and would ask the mother about any suggestive family history. I would consult with the senior emergency department doctor and my consultant. I would admit the child for analgesia and fracture management. I would treat this child with a Pavlik harness for 4 weeks in the expectation that this would stabilise the fracture, allow it to heal and there would be subsequent remodelling. In my hospital, I would contact the on-call paediatrician responsible for child protection who would take the lead in this regard and coordinate any investigation including the involvement of social services and arranging further investigations such as a skeletal survey.

2.  What features in a presentation or injury might make you worry about non- accidental injury?

 Characteristic injuries seen in non-accidental injury are skull fractures, rib fractures, femoral fractures in non-ambulatory children (younger than 18 months), humeral fractures and several co-existing or multiple fractures which may be of different ages. These are increasingly sensitive when seen in combination.

  Other features which should alert the clinician might include a delay in presentation, presentation out of hours and evidence of neglect. Some studies have suggested that metaphyseal corner fractures or certain bruising patterns might indicate non-accidental injury. The evidence for this is less clear. Nevertheless, where there is concern, most hospitals have a clear policy as to how concerns should be raised. I would discuss my concerns with my consultant on call and with the paediatrician on call for child protection.

3.  Are you aware of any relevant literature in this area?

 Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and nonaccidental injury in children: A comparative study. Br Med J (Clin Res Ed). 1986 Jul 12;293(6539):100–102.

A cohort study undertaken over 6 years comparing fracture patterns in children sustained as non-accidental injuries with those where abuse/NAI had been excluded. Multiple fractures, bruising to the head and neck, spiral humeral fractures and rib fractures were associated with NAI. Metaphyseal ‘chip’ fractures were uncommon

  Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S. Patterns of skeletal fractures in child abuse: Systematic review. BMJ. 2008 Oct 2;337:a1518. doi: 10.1136/bmj.a1518.

A systematic review of 32 papers/studies examining fracture patterns in non-accidental injury. No single fracture type or pattern is pathognomic for non-accidental injury; however, multiple fractures are commonly seen in NAI and fractures to the ribs, femur or humerus were also associated with NAI in the absence of major trauma.