Inflicted fractures and other non-accidental musculoskeletal injury — OSCE

Maya is a six-month-old girl who cannot yet crawl, brought to the emergency department by her parents with a swollen, irritable left thigh. The history is a "roll off the sofa" that morning, though the two parents give slightly different versions of who was present, and there was a three-hour delay before presentation. The radiograph shows a spiral femur fracture. On the skeletal survey there is additionally a classic metaphyseal lesion at the distal femur and a posterior rib fracture. Maya has an infant sibling at home. The registrar asks you to assess the injury pattern and to explain the plan to the family.