Intended for healthcare professionals

Endgames Case report

Femur fracture in an infant

BMJ 2009; 338 doi: (Published 14 May 2009) Cite this as: BMJ 2009;338:b1583
  1. Jenny S Radesky, resident in paediatrics,
  2. Naomi F Sugar, clinical professor
  1. 1Department of Pediatrics, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, USA
  1. Correspondence to: N F Sugar, Harborview Medical Center MS 359 947, Seattle WA 98108, USA nsugar{at}

    A 4 month old baby was brought to the emergency department because he was not moving his left leg. The parents reported that the baby twisted and fell when his father was changing his nappy. The father caught the baby by his leg before he hit the floor. The parents noted something was wrong immediately and brought the baby in for care. The baby had been born at full term after an uncomplicated pregnancy and delivery and had normal growth and development. The baby’s parents were married and both employed, and he was their first child. Radiography showed an acute oblique mid-shaft fracture of the left femur. The baby was clearly in pain when he moved, but his leg did not seem to be swollen. The remainder of the examination was normal.


    • 1 How would you evaluate the history of this patient?

    • 2 What other diagnoses should be considered?

    • 3 What other medical tests should be performed?


    Short answers

    • 1 Initial evaluation of any trauma in an infant should focus on the mechanism of injury, the plausibility in light of the infant’s motor development, how the caregiver noted a problem, the infant’s medical history, and the reports of witnesses to the event. Even when the history is compatible with the injury, as in this case, a fracture in a pre-mobile infant warrants an evaluation to rule out abuse or underlying pathology.

    • 2 The major differential diagnosis for a fracture in an infant includes accidental injury, child abuse, birth trauma, metabolic bone disease such as rickets, and osteopenia as a result of premature birth or severe dietary deficiency. Rarely, fractures can be caused by congenital biochemical collagen disorders such as osteogenesis imperfecta.

    • 3 A skeletal survey is needed to identify occult fractures and bone …

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