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Trial and Error: Understanding an uncommon fracture

Understanding an uncommon fracture

“No, our family is not supported by a social worker.” Jesse’s mother is visibly annoyed now. “Jesse* is a very energetic child, but we are doing fine.” Jesse, a heated, whining toddler of 16 months old, showed up at the emergency department in his pyjamas tonight. His mother explained that his leg got stuck between the bars of his bed. Now it hurts badly, and the emergency physician found a spiral shaft fracture of the tibia on the X-ray. Our conversation becomes increasingly unfriendly, and after fifteen minutes, she loudly screams that she is not a criminal and takes Jesse home. Communication has broken down making it impossible to further investigate the worries of the emergency physician about possible abuse. We feel forced to report the case to the national child protection agency.

A spiral fracture in a child this age with this presentation warrants a suspicion of abuse.1 “How are the family circumstances?” and “Can Jesse go home with his mom safely?” are important questions to ask. However, the reason for asking these questions should be explained clearly and with sensitivity, before embarking on this line of questioning.

We tried again with 2-year-old Thijs* who presented with a spiral shaft fracture of the tibia some years later. His father told the physicians that he slipped on a football and twisted his leg. However, the emergency physician is unsure about the trustworthiness of this story. He explains: “As you might have heard on the news, there are many cases of child abuse in the Netherlands. Unfortunately, doctors miss most of these cases. I am not saying that your son’s fracture was caused by something other than his fall, but his fracture is uncommon and quite severe for tripping over ball. If we don’t ask some difficult questions in these cases we will keep missing those rare cases of abuse. Therefore, I believe further investigation is needed and your cooperation is required.” Thijs’ father frowns. Then, he nods and says: “I understand”.
* All names are used in a fictitious manner.

R. Beekman & M. Bijlsma


  1. Kemp AM1, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a1518.

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