ED Pathway for Evaluation/Treatment of Child with a Suspected Extremity Fractures

Screen for Indicators of Possible Non-Accidental Trauma

Recommendations

Age Fracture Actions
≤ 12 months Any extremity fracture that is not an exception Social Work consult
Skeletal survey
Abuse, Physical Pathway
SCAN consult
> 12 months Fractures listed below Social Work consult
Skeletal survey if < 2 years
Abuse, Physical Pathway
SCAN consult

For any child with any fracture and positive historical or physical examination indicators of NAT, obtain Social Work consult and refer to the Abuse, Physical Pathway


Fracture Type

Age Location Exceptions
< 12 months Extremity fracture
(Long bones, hands, feet)
In cruising toddlers:
  • Distal buckle fracture of radius/ulna or tibia/fibula
  • Toddler's fracture
Clavicle History of birth trauma in infant < 30 days
History of fall
Any Age Classic metaphyseal  
Multiple fracture sites  

Historical Indicators of Possible Non-Accidental Trauma

  History
Previous history of inflicted injury
Injury present:
  • Without any history of trauma
  • Not consistent with stated history
  • Inconsistent with child’s development
  • Significant changes in the history
Injury occurred as a result of inadequate supervision
Delay in seeking medical care w/o reasonable explanation
Patient lives in a home with a child who has suspected abusive injuries
Children with or w/o obvious injuries resulting from family/domestic violence incident
Witnessed inappropriate behavior to a child placing them at risk for non-accidental trauma

PE Indicators of Possible Non-Accidental Trauma

Bruising Present in non-ambulatory infants
Unusual locations Ear pinnae, neck (under chin), torso, buttocks, flexural
Patterned Loop marks, hand prints, subgaleal hematoma (hair pulling)
Bite Marks  
Burns Patterned, cigarette, stocking –glove, Mirror image burns LE's
Symmetric buttock burns. Immersion burns, burns multiple sites
Eye Retinal hemorrhage