worker cannot obtain emergency placement for child. C. Follow-up. Medical follow-up will depend on type and severity of injuries. Although obtaining signed releases is appropriate, state laws pertaining to criminal investigation and investigation of suspected child abuse take precedence over HIPAA regulations, allowing physicians to discuss otherwise protected health information with CPS workers and police.
VI. Problem Case Diagnosis. The 3-week-old infant has an acute spiral fracture of the left femur, with no explanation given for this injury. Infant was a healthy term neonate, with an uncomplicated prenatal and perinatal course. The spiral nature of this fracture suggests a twisting force applied to the leg. A skeletal survey showed no additional fracture and otherwise normal-appearing bones. CT scan of the head was negative. During the CPS and police investigation, the mother's boyfriend admitted that he might have hurt the infant when he became frustrated while trying to change the diaper. A follow-up skeletal survey 2 weeks later showed multiple healing posterior rib fractures.
VII. Teaching Pearl: Question. How can you be certain the femur fracture in the infant described in the opening problem was not caused by birth trauma?
VIII. Teaching Pearl: Answer. A femur fracture occurring at birth would be expected to cause decreased mobility or "pseudoparesis" of the leg and signs of tenderness shortly after birth, not 3 weeks later. The x-rays themselves show an acute injury with no signs of healing of the fracture. Fractures, except for skull fractures, typically show radiographic signs of healing within 7-14 days of injury. A fracture showing no early signs of healing could not have occurred more than 14 days prior to x-ray. An acute nonhealing fracture in a 3-week-old infant could not have occurred at birth. The healing rib fractures, not seen initially, but seen in follow-up x-rays further emphasize this point.
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