Intrauterine fetal fractures are a rare finding and can represent lethal skeletal dysplasias such as Osteogenesis Imperfecta, or other metabolic or structural abnormalities. More than 400 skeletal dysplasias have been described; some are associated with classical modes of inheritance, while others are associated with imprinting errors, mosaicism, and teratogen exposure. Accurate prenatal diagnosis is critical for appropriate patient counseling, pregnancy management and expected postnatal outcomes. Prenatal ultrasound (US) remains the standard imaging modality for identifying prenatal structural abnormalities; this, coupled with genetic testing, can aid in establishing diagnoses. Available clinical testing includes chromosome microarray, panel testing, exome, and genome sequencing (ES and GS, respectively). Despite the availability of ES and GS, the genetic or molecular mechanism may remain elusive. Here we present a case of suspected campomelic dysplasia which remains a diagnostic dilemma despite thorough genetic evaluation. A 31-year-old Gravida 2 Para 1-0-0-0 at 20 weeks gestation presented for anatomy US at our Maternal Fetal Medicine clinic. This was an IVF pregnancy. Her obstetric history is complicated by one prior emergency Cesarean delivery for a 35-week fetus with decreased fetal movement and non-reassuring fetal heart tones. The neonate passed 5 days after birth with severe encephalopathy of unknown etiology. The patient and partner are otherwise healthy and have no pertinent medical or surgical history. Family history was non-contributory. Initial anatomy US for current pregnancy revealed a singleton female fetus with severely bowed femurs bilaterally with concern for fracture on the right femur, talipes equinovarus of left foot, with all bones showing normal ossification. The fetus was growth restricted at <10th percentile with all shortened long bones. Markers of lethality of skeletal dysplasia including cardiothoracic (CT) ratio was 53% (normal <50%), and femur length (FL): abdominal circumference (AC) ratio was 0.11 (Normal >0.16). These findings prompted diagnostic genetic work up with amniocentesis sent for FISH, chromosome microarray, and a 700 gene skeletal dysplasia panel; all of which returned normal. Sonographic surveillance continued to show a constellation of findings concerning for skeletal dysplasia including bilateral proximal femoral diaphyseal bowing/fractures, left clubfoot, 11 total ribs, micrognathia, chest-to-abdominal circumference CC/AC ratio 0.87, and FL/AC ratio 0.19 (considered severe when CC/AC <0.60 or FL/AC <0.16). Fetal MRI at 32 weeks demonstrated normal fetal brain structure, short femurs, normal lung volumes, unilateral talipes and micrognathia. The patient underwent prenatal ES, which was negative for pathogenic or likely pathogenic variants associated with the prenatal phenotype. The patient underwent a repeat Cesarean Delivery at 38w2d and delivered a liveborn female neonate weighing 2670 grams with Apgar scores of 7 and 9 at 1 and 5 minutes respectively. ENT was available at bedside for possible neonatal airway compromise. On postnatal physical exam, the neonate was normocephalic with age appropriate fontanelles. There was micrognathia with intermittent airway obstruction and evidence of Pierre Robin sequence. The spine was straight without lesions, both femurs were shortened with clubbing of the left foot. All fingers and toes appeared normal. A skeletal survey revealed 12 ossified rib pairs, hip dislocation, lateral bowing/angulation of the mid femoral diaphyses, as well as club feet bilaterally. No fractures were identified. With exception of hip abduction, she had appropriate movement of her extremities. Postnatal expanded GS was pursued; results revealed no pathogenic, likely pathogenic or variants of uncertain significance. Further research -based testing was pursued through Optical Mapping; this revealed several genomic insertion, deletion, inversion, duplication, and translocation events involving multiple genes. However, after review by our Center for Individualized Medicine (CIM) Genomic Odyssey Board (GOB) team, none of the reported genomic events were felt to be a good fit with the infant’s phenotype. This case remains a diagnostic dilemma. Rapid GS and research based optical mapping failed to identify an underlying genetic etiology. This case illustrates challenges associated with prenatal diagnosis of suspected skeletal dysplasias.