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Child Abuse

Spiral Fracture and Abuse

08/16/2001

Question:

Spiral fractures in babies are warning signs of abuse. A 9 month old baby girl in the first stages of walking (a few faltering steps) recieves a spiral fracture to the mid femur. The mother cannot provide a reasonable explanation for the break, saying she pushed her baby (who slept with her and her partner) out of bed in the middle of the night. When the baby wouldn`t stop crying the following morning, she took her to the hospital. There are no other obvious signs of abuse. The baby is healthy, well nourished, and happy, and there is an older sibling with no history of abuse.

1/ Is it reasonably possible for a spiral fracture of the femur of a nonambulatory infant to be caused by accident? 2/ Is it reasonably possible that a spiral fracture to the the femur of a nonambulatory infant be caused in the manner described by the mother?

Thankyou.

Answer:

Thank you for your question. You are correct to be concerned about this child. The most important aspects you mentioned are the child’s age and developmental status. The pattern of an isolated femoral shaft fracture cannot be used to rule in or rule out abuse. The fact that the baby is only nine months old raises concerns. Studies have shown that the majority of femur shaft fractures in children less than one year old were attributed to abuse. The index of suspicion was increased if the child was non-ambulatory (i.e. not walking). In your case, the child had just started to begin walking. Hence, abusive injury remains a significant concern. However, what you describe is not enough to assign a cause of injury. Many unanswered questions remain, such as height of the bed and the type of floor. Also, what happened when the baby was “being pushed out of bed”? Did mom realize what happened? Does the partner know anything that could help? Did the baby free fall or roll to the floor? Had the baby’s foot been caught in the bed or bedding, sustaining the injury? As you see, more information is needed. Because of your concerns, a report to the local children’s services should be made. They can then undertake an investigation, which might provide more information.

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Response by:

Robert Shapiro, MD
Professor of Clinical Pediatrics
College of Medicine
University of Cincinnati