Fussiness Following Minor Trauma in an Infant
Radiology Cases in Pediatric Emergency Medicine
Volume 6, Case 2
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
     A 2-month old male infant is brought to the 
emergency department at 10:30 pm with a chief 
complaint of crying and fussiness.  His parents noted 
this since 9:00 pm when they returned home from 
shopping.  His mother was carrying him in a padded 
fabric infant carrier over the front of her body.  His 
mother was carrying a light weight cardboard box as 
she opened the door to their home.  When she turned 
on the house lights, he let out a scream and continued 
to cry inconsolably for a while.  Initially, his parents 
thought that the light awoke him from a nap, although 
his crying seemed excessive.  Their next thought was 
that his arm got caught in one of the straps of the infant 
carrier.  It was dark when they came through the door 
so his parents are not sure if his arm was caught 
anywhere.  Although he has calmed down since the 
incident, he still seems to be very irritable and 
uncomfortable.  He feeds well, but he is intermittently 
very fussy.  There is no history of fever, vomiting or 
cold symptoms.  Prior to 9:00 pm, he seemed to be 
fine.  He passed two normal stools earlier in the day. 
     His past history is unremarkable
     Exam:  VS T36.9.(tympanic), P110, R40, oxygen 
saturation 100% in room air.   He is alert and 
interactive, in no distress.  He is not toxic appearing.  
He is not crying and does not appear to be irritable 
when bounced.  During various aspects of the exam, he 
is crying intermittently, but this appears to be a normal 
reaction to an examiner.   Anterior fontanelle is soft and 
flat.  Head without swelling or tenderness.  Neck 
supple.  Heart regular without murmurs.  Lungs clear.  
Abdomen soft and non-tender.  No hernias are present.  
His testes and penis are normal.  Clavicles are 
non-tender.  His back is non-tender.  Hip range of 
motion is good.  There is no consistent reaction when 
palpating his upper and lower extremities.  His digits 
and penis are examined for hair tourniquets and none 
are found.  Perfusion and color are good.
     His parents' concern appears to be sincere, but 
nothing is found on exam and his fussiness and crying 
seem to have resolved.  His parents are told that his 
condition appears to be benign and perhaps he was 
having some abdominal cramps.  The emergency 
department is very busy.  His parents are told to wait in 
their assigned room for a 30 minute observation period 
after which, the physician would return for a 
     A later reassessment finds the patient to be active 
and alert, but his parents state that he still has 
occasional episodes of unusual crying.  The 
possibilities of constipation and intussusception are 
discussed.  There are no episodes of unusual crying 
witnessed.  His parents are asked to report any crying 
to the nurses.  An additional one hour observation 
period is planned.
     An hour later, the patient volume in the emergency 
department subsides.  His parents indicate that they fed 
him about 2 ounces, but he did not seem to feed with 
his normal vigor.  He is now asleep while mother 
carries him.  His abdomen is soft and non-tender.  His 
parents are instructed to check his abdomen 
periodically since appendicitis may be a possible cause 
of his symptoms.  His upper extremities are palpated 
and then his lower extremities are palpated.  This time, 
crepitus is felt in his left thigh and the infant awoke 
crying.  Radiographs of the left lower extremity are 

View radiographs. 

     These radiographs show an angulated fracture 
through the mid femur.

View a different lateral view.

     This view better delineates the oblique spiral nature 
of the fracture.  From this view, it can be appreciated 
that this is a substantial fracture.  Is the history of this 
injury consistent with these radiographic findings?  
Since this is a femur fracture, there should be a history 
of substantial trauma.  This history is lacking in this 
case.  The parents are confronted with the child's 
radiographs.  They are asked if there is any other 
possible injury that they have neglected to tell the 
physician.  They cannot recall any other possible 
trauma.  His mother now believes that the door may 
have hit the box she was carrying at the time and this 
box might have hit him in the leg.  She is told that such 
an injury would require a force greater than this.
     Another possibility is that he received several 
immunizations in his thighs at his pediatrician's office 
three days ago, but he did not seem to be in any pain 
until tonight.
     The family is informed that this case needs to be 
reported to child protective authorities.  Should parents 
always be informed that a report to child protective 
authorities is about to be made?  Is there an easy way 
to inform parents of this?
     In most instances, it is advisable to inform parents 
whenever a report to the child protective authorities is 
made.  This is because they may be very unhappy 
when they find out that such a report has been made.  
If they are upset enough, they will be able to find out 
who made the report and they may possibly retaliate in 
some way.  An easy way to inform parents that a report 
is about to be made is to inform them in a very 
non-judgemental and non-personal way.  Put the 
radiograph with the femur fracture on the viewbox and 
while pointing to the fracture, inform them that there is 
a government law that requires us to report this type of 
injury to the child protective authorities.  I, as a 
physician, have no choice in the matter.  Whenever this 
type of injury occurs, it must be reported.  The child 
protective authorities will be contacting you.  Just tell 
them what happened.
     In ten years of using this approach, I have never 
encountered a reaction that resulted in excessive 
anger or violence.  This approach is non-judgemental 
because it does not accuse anyone of causing the 
injury.  Parents perceive that it is the radiograph that is 
being reported and not them personally.  Likewise, if a 
child comes in with multiple bruises and burns due to a 
history that is not plausible, parents should be informed 
that the government laws require that "these types of 
injuries" (while pointing to the injuries) need to be 
reported to child protective authorities.  Parents 
perceive that the injuries are being reported and not 
them personally.  This is true in many ways because, 
the actual perpetrator cannot usually be determined 
with certainty during the initial medical encounter. 

     Getting back to our 2 month old with the femur 
fracture.  An orthopedic surgeon was consulted.  A 
closed reduction was performed and a femur splint was 
applied.  The child's private physician was notified and 
he indicated that he could not believe that these 
parents were potentially abusive.  The emergency 
physician and the orthopedic surgeon both agreed that 
the manner in which these parents conducted 
themselves was inconsistent with child abuse.  Child 
protective authorities were contacted and they agreed 
to have the infant discharged from the emergency 
department for outpatient orthopedic follow-up.
     At orthopedic follow-up the next day, a skeletal 
survey was performed.

View upper extremity radiographs.

     Note that the earlier lower extremity radiographs did 
not show any evidence of obvious demineralization or 
cysts.  Similarly, his upper extremity radiographs 
appear to be of normal density radiographically.  No 
other fractures were identified on the complete skeletal 
survey.  However, the radiologist noted the possibility 
of Wormian bones on the views of the skull.  The 
radiologist also felt that the long bones were slightly 
demineralized.  The Wormian bone findings were very 
subtle so they are not included here for display.  The 
possibility of Wormian bones raised the possibility of 
osteogenesis imperfecta.  A geneticist was consulted.  
By this time, child protective authorities had 
investigated the home and the parents.  They 
concluded that the likelihood of child abuse was low if 
there could be a medical explanation for the injury.
     A detailed family history done by the geneticist 
revealed a family history of multiple fractures, 
malformations, scoliosis and "bow legs."  No one in the 
family has ever been diagnosed with any congenital or 
chronic bone conditions.  His parents are unrelated.  
His mother and maternal aunt both have scoliosis.  His 
mother fractured her ankle once.  The father is healthy, 
but his father (our patient's paternal grandfather) 
fractured his lower extremity twice and on one 
occasion, this occurred during "horseplay".  
     At this point, the geneticist felt that the infant had 
osteogenesis imperfecta type I or type IV.  Genetic 
studies were sent to a specialized reference lab for 

     There are four types of osteogenesis imperfecta 
(OI).  Type I is characterized by osteoporosis and 
excessive bone fragility, blue sclerae and hearing loss 
in adolescents and young adults.  This is the most 
common form of osteogenesis imperfecta with an 
incidence of about 1 in 30,000 live births.  Inheritance 
is autosomal dominant.  Minimal trauma may result in 
fractures.  About 10% of infants have fractures at birth.  
Bow legs, flat feet, kyphosis and scoliosis are 
commonly seen with OI.  A variant of OI type I is 
associated with dentinogenesis imperfecta (yellow or 
blue-gray translucent teeth which frequently erode or 
break prematurely).  Radiographs show generalized 
osteopenia and healing fractures.  Skin fibroblasts from 
patients show a reduction of type I procollagen 
     Type II osteogenesis imperfecta is a lethal form 
characterized by low birthweight, severe osteopenia, 
crumpled long bones and multiple rib deformities 
(beaded ribs).  Most cases are new mutations, but 
some are autosomal recessive occurring in 1 in 60,000 
live births.  50% are stillborn and the remainder 
eventually succumb to respiratory failure due to the 
skeletal defects of the chest.  The skull is soft and the 
limbs are short.  The skin is fragile as well.  Type I 
collagen (the main collagen of bone) synthesis is 
     Type III osteogenesis imperfecta manifests in the 
newborn or infant with multiple fractures due to severe 
bony fragility.  The sclerae may be blue at birth and 
become less blue with age.  Inheritance is autosomal 
recessive with clinical variability in severity.  Very few 
patients reach adulthood.  Children sustain multiple 
fractures and progressive kyphoscoliosis.  The skull is 
soft and deformed.  Most patients succumb to 
cardiorespiratory complications in infancy or childhood.
     Type IV osteogenesis imperfecta is characterized by 
osteoporosis leading to bone fragility of variable 
severity.  Inheritance is autosomal dominant.  The 
sclerae may be bluish at birth, but this becomes less 
prominent as the patient ages.  Because of variable 
severity, some patients sustain their first fractures in 
infancy, while others sustain their first fractures as 
adults.  There are variable degrees of bow legs, 
scoliosis and short stature.  Many patients show 
spontaneous improvement with age.  This form of OI 
may be occult.  Radiographs may demonstrate 
osteopenia, but this is not as severe as in other forms 
of OI.
     It appears that our patient fits best with OI type IV. 

     Inherited Osteoporoses (Chapter 643).  In:  Nelson 
WE, Behrman RE, Kliegman RM, Arvin AM (eds).  
Nelson Textbook of Pediatrics, 15th edition, 
Philadelphia, PA, W.B. Saunders Company, 1996, pp. 
     Poitras B, Rivard CH.  Pathologic Fractures (chapter 
56).  In:  Letts RM (ed).  Management of Pediatric 
Fractures,  New York, New York, Churchill Livingstone, 
1994, pp. 1027-1048.

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Web Page Author:
Loren Yamamoto, MD, MPH
Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine