Tales of a First year medical resident: Fracture in a pediatric patient

One of the important rules of Pediatrics is a fracture, old or new, visualized on an x-ray of a child has to be investigated. The first line of investigation is medical and key aspects of that are history taking and physical exam. If the medical team is unable to satisfy the cause of the fracture as a non-suspicious event then further prodding begins, often times ending with the involvement of child protective services. Such is the story of baby X.


Baby X is a 1 month old female with no significant medical history.


Mum notices one evening that her baby's toes are swollen. She and dad discuss coming to the ER but decide if the swelling does no go down, they will follow up with the baby's Pediatrician in the clinic the next day. The baby ends up getting admitted as a case of dactylitis (sausage digits) of unknown cause. Per the history from mother there is nothing of significance to explain the swelling; no trauma; no fever; no rash; no recent travel; no family history of joint swelling; uncomplicated birth history. In addition, mom states she is always close enough to the baby and would know if something happened. On physical exam the baby is perfect (not a medical descriptor) other than the swelling of digits. 


So the medical investigations to find the cause of the swelling begin: could it be an infection? what about some type of rheumatologic process? could it be an endocrine disorder? what about gout? There has been noted to be an association of dactylitis with pediatric tuberculosis, could it be that? All of these were ruled out with the relevant blood work and other testing. The next step is imaging so we do an xray of the feet and find fractures. 


After consulting with our child abuse specialist, child protective services are notified because this fracture has happened and there is no explanation. Enter detective work.

It turns out the baby has a 4 yr old sister who after being interviewed by the detective mentions she stepped on baby's feet while playing with him. The mechanism of injury has been identified. But the plot thickens. If Sister Y had indeed been the cause of the injury (which according to the Orthopedic specialist is entirely possible), why did baby X not have a crying fit sufficient enough to alert mum that something happened, especially if the mother is always close enough to the baby? Now the parents are being investigated for negligence and risk losing not just baby X, but 4yr old sister Y, and 10 yr old brother Z.

I'm not sure how to react. On the one side I understand the way the system works, unexplained fracture = bad thing. However, are mothers expected to attend to their babies 24/7, without stepping away? Should parents be blamed for every mishap that occurs? I know there are tons of children being abused with no one taking notice, but this situation just seems unfair...All three children have been followed faithfully by their Pediatricians with no issues. This is the first real event of significance that has happened to any of the children in that household. I would recommend that the mother be reprimanded for leaving her 4yr old alone with the baby, maybe even monitored for a few months with unannounced visits. The outcome of this case to me is a little extreme in its measure of 'justice.' But what do I know, I'm just an intern. 

All the characters in this story have been modified to protect the identity of the participants. All images taken from google images.