Sixteen Fractures in a Seven-Month-Old Child Caused by Nonac
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A 7-month-old girl was directed from the first application center. The patient’s history was first obtained from her mother; she stated that the girl fell 15 days ago while being placed in her cradle by her father. She, therefore, had a plaster-splint (right long leg splint and left long leg circular plaster) applied in the hospital they visited. Physical examination revealed general irritability, pain with slight palpation in each extremity, swelling in both knees and ankles, and swelling and pain in both elbows and forearms. The vascular examination was normal. Light reflex in both eyes was natural, and the patient had high irritability during the examination and could not cooperate for abdominal examination. A significant deformity was observed in the sagittal plane of both knees, and almost total edema was seen in both arms. Genitourinary system examination was normal.

A skeletal survey, brain computerized tomography, and abdominal ultrasonography examination were performed. After the skeletal survey, all fractures has detected and recorded. In addition to detection fractures, common periosteal reactions were observed in the femur anterior and post. It was decided to report the case to the official authorities with the suspicion of physical child abuse, taking into account the clinical features of the case (after the event, the time has passed until the admission, multiple fractures in the immobile infant). Detailed history and examination assessment was performed in the forensic medicine unit. When the anamnesis was taken under the supervision of different forensic medicine physicians separately from the parents, the mother made statements that contradicted her first anamnesis. The father stated that it might have happened when the mother was out of town for treatment and the grandmother was looking after the child. Statements, incompatible with the severity of the injury, such as pulling and dragging by the 8-year-old brother, were added to the story.

The patient was taken to the 3rd level pediatric intensive care unit where she could be monitored continuously and followed up without an attendant. Anesthesia consultation was requested. Although there is a low probability of possible metabolic diseases, alkaline phosphatase, calcium, and serum vitamin D3 (25-OH) levels were studied. It was observed that alkaline phosphatase was 325 U/L, calcium 12.6 mg/dL, phosphorus 4.34 mg/dL, and vitamin D3 (25-OH) 42.42 ng/dL were within normal limits. Preoperative hemoglobin was 7.4 g/dL, and 50 cc erythrocyte suspension replacement was performed to prepare for surgery. General anesthesia was administered with endotracheal intubation. A detailed examination was performed under anesthesia. Osteosynthesis was done using closed reduction and cross K-wire for both supracondylar humerus fractures, right distal tibia fracture, right proximal tibia fracture, and left supracondylar femur fracture. Subsequently, closed reduction and intramedullary K-wire fixation were performed for both radius, ulna, and left tibia fractures. Osteosynthesis of the right distal femur was performed using open reduction and fixation with K-wires. A biopsy was taken from the callus tissue from this area and sent to pathology.

After the operation, pelvipedal plaster and long arm splint on both upper extremities were applied. During the follow-up of the patient, the pathology result was recorded. In the Tru-Cut biopsy findings were interpreted as a normal bone healing and did not support metabolic bone disease. The patient was hospitalized for 48 days, during which the social service and legal process continued. At the end of 48 days, according to the preliminary decision, the splints and pelvipedal plaster were removed, and the patient was discharged by the social services department. K-wires were removed after 2 weeks after the completion of the union in all fractures at the 2nd-month control. The last control of the patient was performed at the 6th month. The range of motion was recorded; the elbow range of motion is 0–140°, the left knee range of motion is 0–120°, and the right knee range of motion is 0–100° was observed.