
Hello, I Would Like Clarification On Few Things Please. The

I would like clarification on few things please. The first being, in a baby approximately 8 weeks of age, does a diaphyseal femur fracture that displaces, do so immediately with the trauma or can it be non displaced and then go on to displace later perhaps through manipulation of the legs? I have heard conflicting information regarding this, however, from a book from a paediatric radiologist it says, “the deformity almost always occurs immediately at the time of the fracture and is the result of the relative displaced positions of the broken ends of the bone at the site of the fracture”. Could you confirm if this is correct please?
Also, can an 8 week old baby move and kick a leg with a displaced or even non displaced, if that’s possible, femur fracture with a power of 5 out of 5 and a tone of normal?
Lastly, when examining a baby who presents only with irritability, what examinations are usually performed to help find the cause? If no cause is found, is it usual to suspect sepsis and if so, what is the first course of action to treat this?
Thank you kindly.

I would like clarification on few things please. The first being, in a baby approximately 8 weeks of age, does a diaphyseal femur fracture that displaces, do so immediately with the trauma or can it be non displaced and then go on to displace later perhaps through manipulation of the legs? I have heard conflicting information regarding this, however, from a book from a paediatric radiologist it says, “the deformity almost always occurs immediately at the time of the fracture and is the result of the relative displaced positions of the broken ends of the bone at the site of the fracture”. Could you confirm if this is correct please?
Also, can an 8 week old baby move and kick a leg with a displaced or even non displaced, if that’s possible, femur fracture with a power of 5 out of 5 and a tone of normal?
Lastly, when examining a baby who presents only with irritability, what examinations are usually performed to help find the cause? If no cause is found, is it usual to suspect sepsis and if so, what is the first course of action to treat this?
Thank you kindly.
Details given below
Detailed Answer:
Hi dear,
Welcome to Ask A Doctor service
I have gone through your query in details, and will try to sort it one by one:
1)Whether displacement occur immediately or not, is entirely dependent on the mechanism of injury and the severity of fracture. In sever trauma with heavy blow, immediate displacement can happen. Otherwise, a non-displace fracture is displaced with manipulation, usually by care givers during bathing/massage. Minor fractures(partial diameter) heals without displacement.
2)Babies will restrict movement in a fractured limb in the acute stage, in order to reduce pain. Once the acute stage is passed and inflammation settles down, even if it is displaced, babies will start using the limb in full power, with normal power and tone.
3)When a baby presents with fussiness/irritability, common things to be ruled out out or kept in our mind are: infantile colic(physiological), otitis media, oral thrush, and diaper rash. Sepsis(as in urinary tract infection or meningitis) can present with irritability, but here babies will be dull with poor feeding, and most of the time with temperature abnormality too. In an otherwise active baby, sepsis workup can be withheld initially. If sepsis is suspected in an infant below 2 months, admission and workup is usually warranted.
I hope this answer will help
Let me know if I can assist you further
Dr Muhammed Aslam, Paediatrician

Details given below
Detailed Answer:
Hi dear,
Welcome to Ask A Doctor service
I have gone through your query in details, and will try to sort it one by one:
1)Whether displacement occur immediately or not, is entirely dependent on the mechanism of injury and the severity of fracture. In sever trauma with heavy blow, immediate displacement can happen. Otherwise, a non-displace fracture is displaced with manipulation, usually by care givers during bathing/massage. Minor fractures(partial diameter) heals without displacement.
2)Babies will restrict movement in a fractured limb in the acute stage, in order to reduce pain. Once the acute stage is passed and inflammation settles down, even if it is displaced, babies will start using the limb in full power, with normal power and tone.
3)When a baby presents with fussiness/irritability, common things to be ruled out out or kept in our mind are: infantile colic(physiological), otitis media, oral thrush, and diaper rash. Sepsis(as in urinary tract infection or meningitis) can present with irritability, but here babies will be dull with poor feeding, and most of the time with temperature abnormality too. In an otherwise active baby, sepsis workup can be withheld initially. If sepsis is suspected in an infant below 2 months, admission and workup is usually warranted.
I hope this answer will help
Let me know if I can assist you further
Dr Muhammed Aslam, Paediatrician


Thank you very much for your detailed reply.
So just to clarify, if a baby was to sustain a leg fracture, it would initially restrict the movement of the leg and there would most likely be swelling, it is once the swelling has died down that the baby will then start to use its leg again? If this is right, on an average approximate time scale, are we talking from fracture occurring to attempting full movement of the leg to be a few hours, a day, a few days etc?
Even if no swelling is apparent within 24 hours of a leg fracture sustaining, would the pain alone be enough for the baby to not move its leg or would it still be able to move its leg in full power?
Also, when a baby 2 months old or less as you say is admitted for sepsis, you say workup is warranted. What exactly should be done? Should antibiotics be commenced immediately? How about other investigations such as lumbar puncture, chest X-ray etc? How quickly should everything happen, all on the same day or is it ok to delay further investigations till the following day?
Thank you so much for your help.
Kind regards

Thank you very much for your detailed reply.
So just to clarify, if a baby was to sustain a leg fracture, it would initially restrict the movement of the leg and there would most likely be swelling, it is once the swelling has died down that the baby will then start to use its leg again? If this is right, on an average approximate time scale, are we talking from fracture occurring to attempting full movement of the leg to be a few hours, a day, a few days etc?
Even if no swelling is apparent within 24 hours of a leg fracture sustaining, would the pain alone be enough for the baby to not move its leg or would it still be able to move its leg in full power?
Also, when a baby 2 months old or less as you say is admitted for sepsis, you say workup is warranted. What exactly should be done? Should antibiotics be commenced immediately? How about other investigations such as lumbar puncture, chest X-ray etc? How quickly should everything happen, all on the same day or is it ok to delay further investigations till the following day?
Thank you so much for your help.
Kind regards
See detailed answer
Detailed Answer:
Hi dear,
Welcome back
As before, I will clarify one by one:
1)Baby will initially restrict movements; but swelling is not a must. Swelling becomes obvious when the fracture is displaced or if the bone is subcutaneous. Usually it will take few hours(24-72 hours) for inflammation to settle and baby starts moving the limb. The period depends on severity of fracture also. Major ones needs immobilisation until healing is over(few weeks)
2)Pain is enough to restrict movement, even if no swelling/displacement.
3)The extent and rapidity of sepsis workup is decided on clinical background.
In an otherwise well and feeding baby, just a blood routine and CRP will be enough initially. Depending on the result, we can either stop or proceed further.
When antibiotics are started on clinical grounds, blood culture is a must; but lumbar puncture is decided clinically.
In a sick baby with disturbed vitals- no question- immediately admit, take out all samples(blood, urine, CSF) and give broad spectrum antibiotics. Delay of even minutes not justified in such cases.
Hope I have answered your query
If you need further clarification, I will be happy to help; otherwise you can close the discussion and kindly rate the answer.
Regards, Dr Aslam

See detailed answer
Detailed Answer:
Hi dear,
Welcome back
As before, I will clarify one by one:
1)Baby will initially restrict movements; but swelling is not a must. Swelling becomes obvious when the fracture is displaced or if the bone is subcutaneous. Usually it will take few hours(24-72 hours) for inflammation to settle and baby starts moving the limb. The period depends on severity of fracture also. Major ones needs immobilisation until healing is over(few weeks)
2)Pain is enough to restrict movement, even if no swelling/displacement.
3)The extent and rapidity of sepsis workup is decided on clinical background.
In an otherwise well and feeding baby, just a blood routine and CRP will be enough initially. Depending on the result, we can either stop or proceed further.
When antibiotics are started on clinical grounds, blood culture is a must; but lumbar puncture is decided clinically.
In a sick baby with disturbed vitals- no question- immediately admit, take out all samples(blood, urine, CSF) and give broad spectrum antibiotics. Delay of even minutes not justified in such cases.
Hope I have answered your query
If you need further clarification, I will be happy to help; otherwise you can close the discussion and kindly rate the answer.
Regards, Dr Aslam


With a displaced fracture of the femur in a baby, how long would it be before you expect to see swelling?
Lastly, if pain alone is enough to stop movement and there is no inflammation or swelling, how long is it before a baby may attempt to move the leg? You mentioned before, after acute stage, how long is this usually?
Thank you so much.
Kind regards.

With a displaced fracture of the femur in a baby, how long would it be before you expect to see swelling?
Lastly, if pain alone is enough to stop movement and there is no inflammation or swelling, how long is it before a baby may attempt to move the leg? You mentioned before, after acute stage, how long is this usually?
Thank you so much.
Kind regards.

I apologise but I have just one more question please. How would you test the power and tone of an approximately 8 week old baby? Is it possible to this just by looking or would you need to physically touch the baby?
Thank you, I really appreciate your help.
Kind regards.

I apologise but I have just one more question please. How would you test the power and tone of an approximately 8 week old baby? Is it possible to this just by looking or would you need to physically touch the baby?
Thank you, I really appreciate your help.
Kind regards.
Kindly see detailed answer
Detailed Answer:
Hi dear,
There is no need to apologise, we are here to help you and are happy to do that to any extent.
The swelling in a displaced fracture is immediate after trauma. This is contributed not only by inflammation but also by the deformity of the broken bone.
In minor fractures, pain will settle in 24-72 hours, allowing baby to use the limbs normally. In major fractures, as I mentioned earlier, we have to immobilise the limb in a cast for few days-weeks.
Power is examined in babies by both observing the spontaneous movements and by palpation. Young infants resists passive extension of limb joints- allowing assessment of power.
Tone, as in older children, is mainly assessed by passively moving the joints. Anyhow, just observing them also will give a clue towards tone. A baby with hypotonia shows diminished spontaneous movements and assume a particular posture(pithed frog posture).
At the end, I would like to make a comment that, fractures are rare in new borns. Usually this happens during a difficult delivery(most commonly involving clavicle or upper limbs). If fracture occur after delivery with no history of a significant trauma, we have evaluate for diseases affecting bone strength, like Osteogenesis imperfecta
If you need further clarification, I will be happy to help; otherwise you can close the discussion and kindly rate the answer.
Regards, Dr Aslam

Kindly see detailed answer
Detailed Answer:
Hi dear,
There is no need to apologise, we are here to help you and are happy to do that to any extent.
The swelling in a displaced fracture is immediate after trauma. This is contributed not only by inflammation but also by the deformity of the broken bone.
In minor fractures, pain will settle in 24-72 hours, allowing baby to use the limbs normally. In major fractures, as I mentioned earlier, we have to immobilise the limb in a cast for few days-weeks.
Power is examined in babies by both observing the spontaneous movements and by palpation. Young infants resists passive extension of limb joints- allowing assessment of power.
Tone, as in older children, is mainly assessed by passively moving the joints. Anyhow, just observing them also will give a clue towards tone. A baby with hypotonia shows diminished spontaneous movements and assume a particular posture(pithed frog posture).
At the end, I would like to make a comment that, fractures are rare in new borns. Usually this happens during a difficult delivery(most commonly involving clavicle or upper limbs). If fracture occur after delivery with no history of a significant trauma, we have evaluate for diseases affecting bone strength, like Osteogenesis imperfecta
If you need further clarification, I will be happy to help; otherwise you can close the discussion and kindly rate the answer.
Regards, Dr Aslam


Thank you so much, you’re being extremely helpful.
You mention osteogenesis imperfecta, is this something that would require genetic testing or can it be diagnosed clinically?
Is it true that the clinical evidence overrules the genetics? Because as advanced as medical science currently is, there are still some gene mutations we are not aware of as of yet which is why it is best to rely on physically examining the baby to check for characteristics and diagnosing based on that rather than a genetic test that may come back all clear, if that makes sense?
And in your opinion, how likely is it to miss a fracture of the femur on a baby who presents to you with no history of trauma and nothing but irritability?
Thank you,
Kind regards.

Thank you so much, you’re being extremely helpful.
You mention osteogenesis imperfecta, is this something that would require genetic testing or can it be diagnosed clinically?
Is it true that the clinical evidence overrules the genetics? Because as advanced as medical science currently is, there are still some gene mutations we are not aware of as of yet which is why it is best to rely on physically examining the baby to check for characteristics and diagnosing based on that rather than a genetic test that may come back all clear, if that makes sense?
And in your opinion, how likely is it to miss a fracture of the femur on a baby who presents to you with no history of trauma and nothing but irritability?
Thank you,
Kind regards.
Genetic testing complements clinical findings
Detailed Answer:
Hi dear,
Osteogenesis imperfecta needs genetic testing for confirmation, but can be suspected clinically if we see a baby with fractures even with minor trauma. The age of presentation and susceptibility to fracture depends on the type(there are more than 10 subtypes). Even if we diagnose it clinically, genetic testing is needed for genetic counselling and prenatal testing during future pregnancies.
In practice, we can not separate clinical findings from genetic testing. Both have their own roles and complement each other in diagnosis. Some diseases like Down syndrome are so obvious clinically, but occasionally we may not be able to spot the genetic abnormality easily during testing. On the other hand, there can be genetic abnormality that is clinically silent(as in thalassemia minor). So it is a combined approach.
I will not suspect fracture in a baby presenting with irritability alone if there is no movement restriction or tenderness on examination unless there is a supporting positive family history. Chances are less to miss a bone fracture, as it almost always causes some pain/asymmetry in limb movements following a fall/trauma.
Hope I have answered your query
Let me know if I can assist you further
Regards, Dr Aslam

Genetic testing complements clinical findings
Detailed Answer:
Hi dear,
Osteogenesis imperfecta needs genetic testing for confirmation, but can be suspected clinically if we see a baby with fractures even with minor trauma. The age of presentation and susceptibility to fracture depends on the type(there are more than 10 subtypes). Even if we diagnose it clinically, genetic testing is needed for genetic counselling and prenatal testing during future pregnancies.
In practice, we can not separate clinical findings from genetic testing. Both have their own roles and complement each other in diagnosis. Some diseases like Down syndrome are so obvious clinically, but occasionally we may not be able to spot the genetic abnormality easily during testing. On the other hand, there can be genetic abnormality that is clinically silent(as in thalassemia minor). So it is a combined approach.
I will not suspect fracture in a baby presenting with irritability alone if there is no movement restriction or tenderness on examination unless there is a supporting positive family history. Chances are less to miss a bone fracture, as it almost always causes some pain/asymmetry in limb movements following a fall/trauma.
Hope I have answered your query
Let me know if I can assist you further
Regards, Dr Aslam


Thank you again for this.
So if a baby displays signs of joint hypermobility, blue/grey sclera and unexplained fractures but has a genetic test which comes back with no abnormalities, it’s unlikely it is caused by a bone disease?
If this is right, what would explain the physical symptoms?
Thank you so much,
Kind regards.

Thank you again for this.
So if a baby displays signs of joint hypermobility, blue/grey sclera and unexplained fractures but has a genetic test which comes back with no abnormalities, it’s unlikely it is caused by a bone disease?
If this is right, what would explain the physical symptoms?
Thank you so much,
Kind regards.
Might need more detailed genetic testing
Detailed Answer:
Hi dear,
As I mentioned before, if clinical features are suggesting(weak joints, blue sclera, multiple fractures), we have to take this as osteogenesis imperfecta.
Initial genetic study incorporates common/major mutations only. If that comes normal and clinical suspision is stronger, we may have to do further detailed genetic evaluation. Actually, this is how newer and newer mutations are added to the list. But this is feasible in higher centres with research setup only.
Hope I have answered your query
Wishing you good health

Might need more detailed genetic testing
Detailed Answer:
Hi dear,
As I mentioned before, if clinical features are suggesting(weak joints, blue sclera, multiple fractures), we have to take this as osteogenesis imperfecta.
Initial genetic study incorporates common/major mutations only. If that comes normal and clinical suspision is stronger, we may have to do further detailed genetic evaluation. Actually, this is how newer and newer mutations are added to the list. But this is feasible in higher centres with research setup only.
Hope I have answered your query
Wishing you good health


Thanks again!
Kind regards.

Thanks again!
Kind regards.
You are welcome
Detailed Answer:
Hi dear,
You are welcome, and thank you for the kind words
Hope your query is answered now
If you don not have any other queries, you can close the discussion and kindly rate the answer.
Wishing you good health
Dr Aslam

You are welcome
Detailed Answer:
Hi dear,
You are welcome, and thank you for the kind words
Hope your query is answered now
If you don not have any other queries, you can close the discussion and kindly rate the answer.
Wishing you good health
Dr Aslam

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