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PHYSICAL ABUSE
CLINICAL PEARLS AND PITFALLS
Spiral fractures and metaphyseal–epiphyseal injuries in nonambulatory
children are highly suspicious for nonaccidental trauma (Fig. 111.6 ).
Nonaccidental trauma should be considered for children with a fracture
in the absence of a history of substantial trauma, or if any of the
following are present:
Multiple fractures, which may be in various stages of healing
Delayed presentation with evidence of bone healing at time of ED visit
Presence of rib fractures (particularly posterior)
Femur fracture in a nonambulatory child
Midshaft humeral fracture (less than 3 years old)
History inconsistent with the developmental stage of the child
Among all childhood fractures, nonaccidental trauma accounts for a relatively
small proportion of these injuries. However, of children who have been
investigated for abuse, up to a third of these children have skeletal fractures (
Table 111.2 ). These fractures may be occult, and usually occur in infants and
toddlers. The presence of multiple fractures occurs more often with nonaccidental
trauma. If there is suspicion for nonaccidental trauma as the cause of the fracture,
a child protection team should be consulted for further evaluation and
management, including the determination of need for a skeletal survey to assess
for other occult fractures (see Chapter 87 Child Abuse/Assault ).