Non Accidental Injury

Intentional

Step 1: View clinicals

A 1 year old boy presents with a swelling of his right elbow joint for 4 hours. His mother says that this occurred after he tripped and hit his elbow on the floor. He was diagnosed with severe Hemophilia A at 7 months of age, after developing an epidural hematoma following a fall from his cradle. Since then, he has experienced a mild nose bleed, and a large bruise over his left knee, both following falls. At the time of diagnosis, factor VIII activity was measured to be 0.9%. He is currently on recombinant factor VIII prophylaxis. His medical and surgical histories are otherwise unremarkable. His family history is significant for a maternal uncle with Hemophilia. All immunizations are up to date. He lives with his mother and stepfather.


Step 2: Order all relevant investigations

Coagulation Profile + APTT Mixing Study

PT: 10 sec (10-12) INR: 1.1 (0.8- 1.2) APTT: 51 sec (30-45) Bleeding Time: 5 min (3-10) 1:1 APTT Mixing Study: APTT is corrected

Factor VIII Inhibitor levels

No factor VIII inhibitors are detected.

X-Ray R/Elbow Joint

There is a bucket-handle fracture of the right distal humerus. An associated joint effusion is also noted.

Skeletal Survey

There are partially healed fractures of the 6th, 7th, 8th and 9th ribs posteriorly. No other fractures or bony deformities are seen.


Step 3: Select appropriate management

Recombinant Factor VIII
Inform Legal Authorities
Orthopedic Referral
Desmopressin


Score: ★★☆