Bilateral fibular fractures in a pre-ambulant infant
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CASE REPORT
Bilateral fibular fractures in a pre-ambulant infant Michael Paddock 1,2 & David Horton 3 & Amaka C. Offiah 2,4 Received: 17 January 2020 / Revised: 29 April 2020 / Accepted: 22 May 2020 # The Author(s) 2020
Abstract Multiple long-bone fractures, particularly bilateral fractures, are of moderate specificity for inflicted injury (physical abuse) in infants and young children. Bilateral healing fractures of the fibulae are rare and, depending on age, raise the suspicion of inflicted injury. We report healing undisplaced fractures of both fibulae, in almost identical positions, in a pre-ambulant infant. The caregivers reported that the infant repeatedly banged his legs against the metal frame of his playpen. A video of this mechanism was provided to the instructed radiology expert and showed that the point of impact of the infant’s legs against the metal frame was at a similar level to the radiographic abnormalities. This mechanism was therefore believed to be consistent with the injuries, resulting in a diagnosis of self-inflicted bilateral fibular fractures and not of inflicted injury. Keywords Fibula . Fracture . Infant . Inflicted injury . Nonaccidental injury . Radiography . Suspected physical abuse
Introduction
Case report
Inflicted injury (also termed non-accidental injury) is more common in infants and young children under the age of 2 years, in particular in those younger than 12 months old [1]. Multiple long-bone fractures, specifically those which are bilateral, are moderately specific for physical abuse. Bilateral healing fibular fractures are rare; they are said to be non-specific injuries, indicative of indirect forces, but usually indicate inflicted injury (physical abuse) when associated with other injuries [2], particularly in pre-ambulant infants. We present a case of self-inflicted healing fractures of both fibulae in a 6-month-old pre-ambulant infant, confirmed by video evidence.
A 6-month-old boy was presented to his general practitioner after his caregivers noticed that he was not holding or using his left leg in a normal manner. He was given a diagnosis of transient synovitis and discharged home. His caregivers persistently sought medical attention for the limited use of his left leg: He was presented to the emergency department 3 days later, and again 6 days after his initial presentation to his general practitioner. No other concern was reported and there was no relevant medical history of note. The clinical teams found nothing suspicious in the caregivers’ behaviour or social history. There was no history of illicit drug or excessive alcohol use, the family was not previously known to social services, and the boy’s immunisations were up to date. The child was well cared for and there were no bruises, scratches or other stigmata of abuse. Anteroposterior and lateral radiographs of the left leg demonstrated a subtle undisplaced fracture of the left fibula but were initially reported as normal (Fig. 1). An orthopaedic follow-up radiograph (Fig. 2) performed 2 days later because
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