spiral fracture in a case of congenital rickets

[michi9743]

A 2 month old baby presented with greenstick fractures of the left tibia and right femur, as well as a spiral fracture of the right femur. Radiographic findings were suggestive of rickets, and test results revealed untraceable vitamin D levels in the infant, and deficient levels (18) in the host mother, suggesting congenital rickets. The two hairline fractures were said to be non-trauma related and attributed to the rickets, but radiologists were saying that the spiral fracture was strongly suggestive of child abuse, and both the infant and his two year old brother were removed from the home. There has been no prior history or concerns of abuse, and the parents reactions seem very appropriate. Explanations given include one incident where the infant began to fall out of a baby sling, with his right leg caught in the material, another where the child was being put into a front pack carrier and his leg was caught in the hole, and the mother reached to grab/twist the leg to feed it through the hole. Other possible explanations include aggression from the 2 yr old, or possibly during diapering. How much force does it take to cause this type of fracture in an infant with this disease, and are any of these explanations plausible?

[Deanna L Aftab Guy, MD]

You have got to have an abuse expert review this and a pediatric radiologist see this child, the calluses need to be timed on the film if possible, in my past general pediatric experience, a spiral fracture is not a simple accident, 2 month olds are rather flexible, it takes force and twisting to cause a spiral fracture on new bones, hence the greenstick, explore the possibility of osteogenesis imperfecta, I hate to hear many "stories" to explain this poor babies fractures, 2 month olds don't get misplaced or misattended to, we usually hold their heads and cradle them and handle them with ultra care, if a "by accident" event caused forceful twisting enough to break a femur this is highly suspicious and now that 2 stories are arisen I would have the team pry for more, we don't want to suspect the parents, we want to put the baby first and in a safe environment. Involve the team, this includes abuse experts, emergency physicians and pediatric radiologists and or orthopedic specialists if possible. Not an endocrine problem completely, just bad thing that happened to a baby with an endocrine problem. Poor thing.