Question
A 4 month old baby is brought in with a swollen thigh. The parents say she rolled off the couch. Radiographs show a spiral femoral fracture and healing rib fractures.
- What features suggest non-accidental injury?
- How would you investigate?
- What are your responsibilities?
Answer
Features of non-accidental injury
- Fracture in a child who is not yet walking
- History inconsistent with the injury or the child’s development, changing history or delay in presentation
- Multiple fractures of different ages
- Fractures with high specificity, such as posterior rib, metaphyseal corner (classic metaphyseal lesion), scapula, spinous process and sternal fractures
- Bruising in infants, burns and torn frenulum
Investigations
- Full skeletal survey, repeated at 2 weeks
- Head CT or MRI for intracranial injury
- Ophthalmology review for retinal haemorrhage
- Bloods to exclude bone and bleeding disorders, including calcium, phosphate, vitamin D, ALP and coagulation
- Consider osteogenesis imperfecta and rickets
Responsibilities
- Admit the child for safety
- Mandatory reporting to child protection services in every Australian state and territory
- Involve the paediatric and child protection team
- Document clearly and objectively
- Treat the fracture as for any infant femoral fracture, usually in a Pavlik harness or spica
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.