Identifying non-accidental trauma is a major challenge for any physician. We are the first-line advocates and have a responsibility to report any suspicion of child abuse.
When should I be considering Non-accidental Trauma (NAT)?
ALWAYS think about it. Especially when pediatric patients have fractures or ecchymosis where:
Mechanism does not fit the injury
There is a delayed presentation in seeking medical attention or
Multiple presentations for trauma or fractures.
History, history, history!
4-year-old boy is brought in by his mother three days after falling down the stairs. He has not been walking since his fall. You notice posterior leg ecchymosis, chest ecchymosis and a very quiet disheveled 4-year-old boy.
The key to diagnosing non-accidental trauma is listening carefully to the history and asking important questions:
When did the injury occur?
Where did the injury occur?
Who else takes care of the child? (Daycare workers, father 50% of the time, grandparents etc.)
Who was around at the time of the fall?
Details about the fall?
Fell to Carpeted floor, ceramic floor?
How many stairs did they fall from?
CONSISTENCY: Questions to ask yourself as the patient advocate.
Is the injury consistent with the mechanism?
Is the injury consistent with the child’s age?
Femur fracture in a non-ambulating infant is highly suspicious
Is the history consistent or is it changing the more you delve into the story?
Mnemonic
What to look for on history, physical exam or x-rays:
Boys Have Bruises Not Because Playing with Monkey Bars
Bruises: numerous bruises. Especially posterior bruises, when kids play they may fall forwards and bruise anterior calves and posterior aspect of their limbs is often spared.
Healing stages: bruises/injuries at different stages of healing
Burns: immersion pattern burns, cigarette burns
Non-ambulatory: limb fractures in pediatric patients who developmentally do not walk yet!
Bucket Handle Fracture: metaphyseal fracture aka corner fractures (see image above)
Posterior rib fractures
Multiple injuries and presentations to the ED
Behavior change