X-rays of the femur reveal a spiral femoral shaft fracture. What is the best next step?
A. Bone scan
B. Comprehensive genetic testing
C. CT scan of the head
D. No further testing required
E. Skeletal survey
Answer
Choice “E” is the best answer. A spiral femoral shaft fracture in a non-ambulatory child is considered non-accidental injury (NAI), or physical abuse, until proven otherwise. The fracture occurs through a torsional force (twisting) applied to the leg. Skeletal survey is necessary to look for other (acute and old) fractures. Other fracture patterns that are often …show more content…
This child has multiple fractures and if NAI was unlikely or ruled out, multiple fractures could be concerning for brittle bone disease, or osteogenesis imperfecta (OI). OI is caused by a mutation in type I collagen that leads to the formation of weak, brittle bone. The phenotypic expression is highly variable but in the most severe forms, patients experience multiple fractures and require frequent orthopedic procedures in their lifetimes. Since this stem includes clues of NAI (posterior rib fractures, bruises in various stages of healing, disheveled and seemingly neglected child), a genetic etiology is less