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
reassessment.
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
ordered.
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
confirmation.
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
synthesis.
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
defective.
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.
References:
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.
1978-1980.
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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