Fracture, Extremity, Suspected — Screen for Indicators of Possible Non-Accidental Trauma — Clinical Pathway: Emergency

Fracture, Extremity, Suspected — Screen for Indicators of Possible Non-Accidental Trauma — Clinical Pathway: Emergency

Screen for Indicators of Possible Non-Accidental Trauma

  • Always consider the possibility of non-accidental trauma when evaluating ANY child with a fracture.
  • Careful complete skin exam is important, especially in infants and toddlers.
  • Social Work evaluation is very helpful in elucidating risk factors.

Considerations for Obtaining Skeletal Survey and Social Work Consult

Age Fracture Suggested Actions
≤ 12 months Any extremity fracture that is not an exception
Exceptions in children who are cruising/walking independently include:
  • Distal buckle fracture of radius/ulna
  • Distal buckle fracture of tibia/fibula
  • Toddler's fracture
 Social Work consult
Skeletal survey
Abuse, Physical Pathway
Consider SCAN consult based on results of skeletal survey and Social Work input
> 12 months Fractures listed below:
  • Classical metaphyseal fractures
  • Multiple fracture sites
  • Presence of Hx, PE indicators
 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, refer to the Abuse, Physical Pathway and obtain Social Work Consult


Historical Indicators of Possible Non-Accidental Trauma

History
Previous history of inflicted injury Injury occurred as a result of inadequate supervision
Injury present:
  • Without any history of trauma
  • Not consistent with stated history
  • Inconsistent with child’s development
  • Significant changes in the history
 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

BruisingPresent 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 
BurnsPatterned, cigarette, stocking –glove, Mirror image burns LE's
Symmetric buttock burns. Immersion burns, burns multiple sites
EyeRetinal hemorrhage