Research in practice

A rare differential for non-accidental injury

Case study analysis of a two-year-old admitted to the ED in a case of unexplained fractures

Non-accidental injury (NAI) is a common differential diagnosis in children presenting with unexplained fractures. Multi-agency investigations and strategy meetings are completed at hospital, and although necessary, can create anxiety and stress for the family. Differentials such as osteogenesis imperfecta and rare neuropathies are additional possibilities.


This case study presents a two-year-old admitted via the emergency department (ED) with right tibia and fibula fractures. Additional concerns included marked tenderness and calf swelling with no mechanism of injury witnessed by either parent. Discussions with consultant radiologists specialising in children’s safeguarding suggested significant force from a direct anterior or posterior blow would have been required.

Child protection proceedings were commenced. On discharge, the child and younger sibling were initially placed by social care with a family friend under a working agreement.

Serial outpatient X-rays were undertaken. Two months post-discharge the child was