What Types of Femur Fractures Are Concerning for Possible Child Abuse?

Patient Presentation
A 6-month-old female was transferred to the emergency room of a children’s hospital for treatment of a femur fracture.
Her mother was carrying her down some stairs and fell landing on the infant.
The mother could not give more details of how she was carrying the infant before the fall, how many stairs she fell down,
nor the final position of the infant or herself.
The past medical history showed her to be a full-term infant who had received regular health supervision visits.
The family history was negative for genetic or skeletal disease.
The social history showed two other siblings living with their biological mother and father who are not married.
The mother denies any history of alcohol, drugs or violence.
The review of systems was negative.
The pertinent physical exam showed an alert infant in a leg immobilizer who smiles.
Vital signs were normal. Head circumference was 25%, weight and length could not be done accurately due to the immobilizer.
She appeared developmentally appropriate. Her examination was normal including head, eyes, abdomen, genitalia and skin.
The radiologic evaluation on the radiographs from the outside hospital showed a transverse femur fracture of the diaphysis that was angulated but not shortened.
The diagnosis of a transverse femur fracture was made.
The patient’s clinical course was that she was taken to the operating room where a spica cast was placed.
The following day, an evaluation for possible child abuse was conducted and showed a normal head computed tomography examination, normal skeletal survey, normal ophthalmological evaluation and initial screening laboratories were negative.
The Department of Human Resources was contacted and discharged the infant to a temporary foster care placement along with her siblings.
The Department of Human Resources and the courts determined after further investigation that she had been abused.
She was later placed in permanent foster care and was awaiting adoption. Her femur fracture healed with no residual problems.

Figure 59 – An AP radiograph of the left femur demonstrates a complete fracture of the femoral diaphysis with minimal angulation and overriding of the fracture fragments.

In the western world as early as 1860, Tardius studied child abuse in France but the findings had no impact on the medical community. In 1888, West described periosteal swelling in long bones. Caffey began studies of subdural hemorrhage and associated fractures from 1920-25, but it was his landmark article in the 1946 where he described multiple fractures in multiple bones in multiple stages of healing that is regarded as the one of the first studies to receive widespread attention by the medical community for child abuse.
In Caffey’s series, 5 of the 6 cases had femur fractures.

Stair falls are common occurrences in children but usually do not cause serious injury. Studies of stair falls show that they do not cause significant injury to more than 1 body region and typically do not cause proximal extremity and truncal injuries. Stair falls also cause few bruises even after falling down several stairs.

Stair falls are a common false history for child abuse.
In a prospective study (N=29) of femur fractures with a reported history of a stair fall as the mechanism of injury, Pierce et. al. used an injury plausibility model to evaluate stair falls as a plausible history versus stair falls as a suspicious history for child abuse.
In their model they used:

  • Caregiver history of the fall – could the caregiver describe the elements of the initial position, fall dynamics, and final position. A caregiver who could not give these or fewer elements was more suspicious
  • Fracture and the possible biomechanical mechanism – did the possible biomechanics match the type of fracture
  • Time to seeking care – immediate versus delayed with or without signs of injury. Delayed care with more obvious signs of injury was more suspicious
  • Additional findings or injuries on initial exam – more additional injuries increases suspicion

They pointed out in their study at that initially the caregiver histories did not seem unusual, but additional questioning often found more vague answers that were without detail, and that the fewer the specific elements that the caregiver could describe, the more suspicious the case was.
Spiral fractures in this study only occurred in walking patients and where the leg was reported to be folded or twisted under the patient’s body. If the leg was reported to be pinned under a caregiver’s body, the fractures were commonly transverse or oblique.
Immediately seeking care, or a delay with a subtle or well aligned fracture was not suspicous for child abuse. Any additional injuries to the child were suspicous for child abuse.

Fracture types from stair falls in this study were most commonly buckle or impact fractures (58.6%), transverse or short oblique (24.1%), spiral or long oblique (13.8%), and classic metaphyseal fracture and/or high impact fracture (3.4%)

Learning Point
Child abuse or non-accidental trauma is a clinical diagnosis. It is the constellation of history, physical examination, radiographic evaluation, laboratory testing and investigation that determines if child abuse has occurred.
Fractures can be a presenting symptom of abuse but they are also common problems not associated with abuse.
Femoral shaft fractures are estimated to account for only 1.6% of all fractures in children, therefore they are potentially more suspicous for child abuse.

Scherl et al report a retrospective study of 207 patients with all histories for injury who were 6 years of age or less and had a femur fracture.
Thirteen cases (6.3%) eventually were found to be caused by child abuse and the initially presenting histories were : 4 caused by a fall, 5 with no history of trauma, 1 caused by being hit by a falling object, 1 caused by being hit accidentally by another person and 1 record was incomplete.

Sclerl et. al. report of femur fracture types and causes. All numbers given are percentages.

		Overall	Known	Fall	Pedestrian	No Trauma	Motor
			Child		Struck by	History		Vehicle
			Abuse		Auto				Accident
Sample		100	6.3	43.5	30.4		9.3		4.7

Fracture Type
Transverse	38	36	33	48		40		NA
Spiral		27	36	37	11		35		NA
Oblique		17	7	14	18		10		NA
characterized	14	21	13	17		15		NA
Other		3	0	3	6		0		NA

There is no particular pattern of femur fractures that is pathognomonic for child abuse, therefore all femur fractures could be suspicious. Several early studies found spiral fractures to be the most common fracture type, therefore many clinicians may still believe that spiral fracture are indicative of abuse. Spiral fractures may be caused by other mechanisms.
More recent reports such as the one above, show transverse fractures to be most common overall and more common in child abuse. Therefore clinicians should consider abuse potentially in any child with a femur fracture and in particular with transverse fractures which may be overlooked.

Questions for Further Discussion
1. What other body locations could be concerning for child abuse?
2. What laboratory evaluation should be done during an investigation for possible child abuse?
3. At what ages should a head computed tomography be considered as part of the investigation for possible child abuse?
4. Which fractures are considered radiographically pathognomic for child abuse?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Fractures and Child Abuse and at Pediatric Common Questions, Quick Answers for this topic: Fractures/Dislocations and Child Abuse

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Caffey J. Multiple Fractures in the Long Bones of Infants Suffering From Chronic Subdural Hematoma. AJR. 1946;36(2);163-173.

Scherl SA, Miller L, Lively N, Russinoff S, Sullivan CM, Tornetta P 3rd.
Accidental and nonaccidental femur fractures in children. Clin Orthop Relat Res. 2000 Jul;(376):96-105.

Pierce MC, Bertocci GE, Janosky JE, Aguel F, Deemer E, Moreland M, Boal DK, Garcia S, Herr S, Zuckerbraun N, Vogeley E.
Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics. 2005 Jun;115(6):1712-22.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

  • Systems Based Practice

    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    April 28, 2008