November Week 3: Non-Accidental Trauma

Asnes A, et al. Managing Child Abuse: General Principles. Peds in Review. 2010;31;47-55
Sirotnak A, et al. Physical Abuse of Children. Peds in Review. 2004:25;264-277

Case 1:
An 18 month old boy follows up with you after ER visit for acute leg pain after a fall. The parents state the child was in the living room playing alone when they heard him crying. He was inconsolable and parents took him to the ER about 1 hour later. Xray in the ER revealed a nondisplaced spiral fracture of the distal tibia.

What other questions would you ask? What aspects of an injury history are more suspicious for abuse? 
Do you think this injury is more likely abuse or more likely accidental?
Besides a thorough history, what else is important to document at this visit?

Case 2:
You are seeing an 18 month old girl on your ER rotation who is coming in for left leg pain. Her mom reports she was jumping on her brother’s bed this morning and fell off 2 feet to the floor. She has refused to bear weight since then. Xray reveals an acute nondisplaced femur fracture. You order a skeletal survey which shows corner fracture of right medial distal femur and 2 healing fractures of left ribs.

What are risk factors for abuse? 
Which injuries are more likely to be sequelae of abuse? 
When should you report suspected abuse? When does abuse need to be reported immediately vs waiting a day or two? 
How do you report it? 
Who are mandatory reporters in the community? 
You meet with a CPS SW and a police officer who would like you to give the ages of the child’s fractures and bruises as well as who you think most likely inflicted the injuries. What do you tell them?