Hypnotherapy Case Studies
A 6-month-old male is brought to the emergency department by his mother. She states that the child seems to be favoring his right lower leg and has not been moving it much for the past week. The mother also states that she has noticed swelling in the right thigh for about the same time period. Per the mother’s report, the child has been afebrile and has had no recent illnesses. On exam, the child is alert and appears unkempt, with dirty and malodorous clothing. The right thigh is swollen and tender. Gentle rotatin of the hip and knee while supporting the thigh is not painful. Distally, he moves the foot and toes when tickled and has a 2+ dorsalis pedis pulse. Examination of the back and thorax reveals multiple different colored ecchymoses.
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…
associated with physical abuse are metaphyseal corner fractures and rib fractures. Skull, sternum, and scapula fractures should also be considered to be possibly attributable to NAI. Context is extremely important when dealing with NAI. If the story (mechanism of injury) does not appear to match with the injury or if there is an unreasonable and inexplicable delay in presentation, NAI must be considered. Further, soft tissue findings, such as cigarette burns or ecchymoses in various stages of healing (noted by different colors) may be present. Nevertheless, if the story seems inconsistent with the injury in pediatric patients, include physical abuse in the differential diagnosis.
Choice “A” is not the best answer. When non-accidental injury (NAI) is suspected, the role of the physician is to rule out additional injuries. The standard for evaluating for additional fractures is to perform a skeletal survey. This is essentially an extensive series of radiographs of the extremities, spine, skull, chest and abdomen. Bone scan may be used if an occult fracture is suspected, but as this question states, the best test here and in most clinical scenarios is first a skeletal survey.
Choice “B” is not the best answer.
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
likely.
Choice “C” is not the best answer. CT scan of the head is not part of the initial work-up for physical abuse. Unless there is some indication, a CT scan is an unnecessary high dose of radiation in this young patient. Dilated retinal exam is indicated to evaluate for retinal detachment, which is consistent with shaken baby syndrome.
Choice “D” is not the best answer. One must identify this case as one of likely NAI and proceed with the proper work-up described above. Missing a case of NAI places the child back in a dangerous environment where they are susceptible to continued abuse and even death.
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…
associated with physical abuse are metaphyseal corner fractures and rib fractures. Skull, sternum, and scapula fractures should also be considered to be possibly attributable to NAI. Context is extremely important when dealing with NAI. If the story (mechanism of injury) does not appear to match with the injury or if there is an unreasonable and inexplicable delay in presentation, NAI must be considered. Further, soft tissue findings, such as cigarette burns or ecchymoses in various stages of healing (noted by different colors) may be present. Nevertheless, if the story seems inconsistent with the injury in pediatric patients, include physical abuse in the differential diagnosis.
Choice “A” is not the best answer. When non-accidental injury (NAI) is suspected, the role of the physician is to rule out additional injuries. The standard for evaluating for additional fractures is to perform a skeletal survey. This is essentially an extensive series of radiographs of the extremities, spine, skull, chest and abdomen. Bone scan may be used if an occult fracture is suspected, but as this question states, the best test here and in most clinical scenarios is first a skeletal survey.
Choice “B” is not the best answer.
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
likely.
Choice “C” is not the best answer. CT scan of the head is not part of the initial work-up for physical abuse. Unless there is some indication, a CT scan is an unnecessary high dose of radiation in this young patient. Dilated retinal exam is indicated to evaluate for retinal detachment, which is consistent with shaken baby syndrome.
Choice “D” is not the best answer. One must identify this case as one of likely NAI and proceed with the proper work-up described above. Missing a case of NAI places the child back in a dangerous environment where they are susceptible to continued abuse and even death.