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
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