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Thursday, December 5, 2013
Bruising in Spiral Fractures
A four month old infant had been fussy of the previous 3 days, the mother noticed increased fussiness when the infant was being picked up and changed. Mom thought the baby might be teething early because of excessive drooling. Because the baby had not yet mastered the hand eye coordination yet, it wasn`t discovered right away that he wasn`t using his left arm. When mom brought him into the emergency room an xray was taken and a spiral frature was found. The doctor notified CPS and the baby was taken into protective custody. Both mom & dad say they may have picked up the baby or turned him over incorrectly and accidently may have caused it and they are not abusive or ever have been. There is also a nine year old in the house who they believe is innocent. Mom says that she often uses her right arm to grab his left arm (the injured arm) to roll him over to his side while using her left to slide it under his body to lift. Is it possible that this motion could cause this injury? CPS is saying that one of the parents deliberately twisted the arm but there isn`t any bruising or swelling. Can this happen without bruising or other visible symptoms?
Knowledge of appropriate infant and child development is needed when investigating any injury. As you probably recognize, because there is no known trauma that resulted in this fracture, concerns of possible child abuse must be raised. Young infants who are not ambulatory are unlikely to injure themselves and fractures, therefore, in this age group are concerning for non-accidental trauma and warrant a thorough investigation. This investigation should include a skeletal survey to look for occult fractures or suggestion of bone disease, as well as a cat scan or MRI of the head for evaluation of occult intracranial injury. A thorough investigation is also important because serious injuries can be present without significant external bruising or swelling. Other medical causes for unexpected injury must be considered in children with unexplained injury. This medical evaluation is especially critical when the history is inadequate or the mechanism of injury cannot be explained.
The results of the medical work-up combined with details from the family and CPS investigation must then be evaluated collectively to maximize the safety and well-being of the child as well as to avoid any unwarranted removal of children from their families.
Robert Shapiro, MD
Professor of Clinical Pediatrics
College of Medicine
University of Cincinnati