Spontaneous fractures in cerebral palsy

BMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6983.873d (Published 01 April 1995) Cite this as: BMJ 1995;310:873
  1. Christopher J Hobbs,
  2. Jane M Wynne
  1. Consultant community paediatrician Consultant community paediatrician Community Child Health, Leeds LS2 9NP

    EDITOR,—Last year a patient of ours presented to hospital with a chest infection. She was 19 years old, had cerebral palsy, and at the time was chronically malnourished because of feeding difficulties. On the day after the girl's admission her mother noticed a change in her behaviour and that she was sitting on a bean bag in a position that her mother thought was uncomfortable. Later it was realised that her thighs were swollen. Subsequent x ray films showed an oblique fracture of the left femur and a greenstick fracture of the right femur. The fractures were recent and the bones demineralised and thinned.

    Had this child had only one fracture we might have considered that it was a spontaneous fracture. Probably, however, she had been put on the bean bag by a member of staff who did not appreciate her physical deformity and tried to put her in a “good” position. Her mother, visiting shortly afterwards, was aware of her daughter's mood change—something difficult for staff meeting the child for the first time to appreciate.

    Given the history of this case, we suggest that S Lingam and Jane Joester may be incorrect in describing as spontaneous the fractures that they report.1 Our patient was cared for at home, and her father commented that she liked her legs to be passively moved, flexed, and extended. Forced abduction and external rotation to achieve a “good” sitting position probably caused the fractures.

    We have previously seen a 12 year old boy with microcephaly and spina bifida and an unexplained fracture of the femur; he was malnourished and had thin bones. His fracture occurred while his nappy was being changed; there was a “crack,” and he was distressed.

    In our view it is unwise to label these fractures as spontaneous, although the force required may be less than that needed to fracture well mineralised bones. A difficulty arises if a non-accidental injury has occurred: if the fracture has been accepted as spontaneous the child is left unprotected. Children with disability are at greater risk of abuse than their peers, and some of these fractures will be the result of abuse.2 3 Have Lingam and Joester considered why the school attended by the subjects of their reports apparently has such a high incidence of fracture of the femur?


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