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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 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 )
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