Review Question - QID 210135

Any concern for non-accidental trauma (NAT) requires the immediate notification of child-protective services.

The most common cause of femur fractures in non-ambulatory patients is NAT. Red flags concerning for NAT include long-bone fractures in non-ambulatory patients, delayed presentation for treatment, and unwitnessed injuries. Physicians are legally required to report suspected child abuse and neglect in all states. Children with disabilities are at increased risk for abuse. Skeletal survey may reveal other fractures at different stages of healing. However, it is important to keep in mind that skin lesions, not fractures, are the most common presenting signs of child abuse.

Kocher et al. provided an overview for the treatment of pediatric diaphyseal femur fractures. When considering treatment, it is important to take into account fracture characteristics, age, and social factors. They conclude that, despite the recent trend towards surgical fixation in this population, there remains controversy and lack of conclusive evidence in the treatment of these fractures.

Shrader et al. retrospectively reviewed suspected NAT and femoral shaft fractures in children over a 5 year period at a major pediatric Level I trauma hospital. The purpose of this study was to analyze the incidence and risk factors associated with these fractures. Of the 137 femoral shaft fractures during this period, 43 (31%) were suspicious for NAT. They found that age younger than 1 and the presence of Medicaid or uninsured status were both highly significant risk factors for NAT.

Figure A demonstrates an anteroposterior radiograph of a right diaphyseal femur fracture.

Incorrect Answers:
Answer 1: Early spica casting is an option for treating femoral shaft fractures in this age group (6 months to 5 years) with <2-3 centimeters of shortening, however, treatment should not delay immediate notification of child protective services.
Answer 2: Arthrocentesis is not necessary, as radiographs clearly demonstrate a fracture and there is low suspicion for infection based on this patient's labs and vitals.
Answer 3: Magnetic resonance imaging is not required and will not change management.
Answer 4: ORIF with submuscular bridge plating is an option for treating femoral shaft fractures in this age group with >2-3 centimeters of shortening, however, treatment should not delay immediate notification of child protective services.