Suspicious Fracture in a Toddler

Clare Cardo McKegney, APRN, CPNP


J Pediatr Health Care. 2008;22(3):196-198. 

In This Article

Case Study Answers

1. What Are the Differential Diagnoses?

C.R.'s inability to move his arm was suggestive of a fracture, and a nondisplaced supracondylar humeral fracture was confirmed by radiograph. This fracture was noted in the extra-articular aspect of the thin bones between the olecranon fossa of the distal humerus. The fracture line noted was nondisplaced and was visualized from the anterior distal point to the posterior proximal site of the distal humerus. The lack of knowledge regarding the mechanism of injury must raise suspicion for the nurse practitioner (NP).

There is no one fracture that is indicative of nonaccidental trauma; however, fractures that should raise suspicion include multiple fractures in different stages of healing, femur fractures in pre-ambulating children, corner or chip fractures, fractures of the metaphysics around the knee, scapula fractures, and ulnar nightstick fractures (Hart, Albright, Rebello, & Grottkau, 2006). Thomas, Rosenfield, Leventhal, and Markowitz (1991) report that the diagnosis of a nonsupracondylar humeral fracture, especially in children younger than 1 year, is likely due to abuse. Other findings associated with a fracture in a child that are suggestive of abuse include inconsistent history, blaming injury on a sibling, parental over-reaction/under-reaction, fractures inappropriate for age or developmental level, fractures in children younger than 3 years, delay in seeking medical attention, previous incidents, use of many providers, and associated skin lesions (Urbanski & Hanlon, 1996).

When evaluating a child with a fracture, it is important to consider other diseases that simulate abuse. Diseases that should remain in the differential include osteogenesis imperfecta (brittle bone disease), skeletal dysplasia, rickets (vitamin D deficiency), scurvy, vitamin A deficiency, congenital syphilis, hypophosphatasia, osteoid osteoma, and leukemia (Sirotnak, Grigsby, & Krugman, 2004). A detailed medical, family, social, and developmental history and physical examination will aid the practitioner in ruling out these rare disorders. The NP should ensure that radiographs for suspected child abuse be read by a pediatric radiologist. Someone knowledgeable of the fractures associated with these rare disorders could avoid the misdiagnosis of child abuse, thereby providing the child with appropriate care and preventing the stigma associated with abuse investigation.

2. What Is the Suggested Standard of Practice for Forensic Evaluation of Suspected Child Abuse?

A radiograph is appropriate when a child presents with signs of decreased range of motion, localized swelling, and point tenderness. In addition to a detailed history and physical examination, a skeletal series is the gold standard in a forensic evaluation for suspected child abuse in a child who is younger than 2 years or is nonverbal (Sirotnak et al., 2004). Long bone fractures do not pose a threat to the life of a child, but if they are associated with child abuse, the practitioner has an opportunity to remove a child from a threatening environment that could lead to continued assault and possible death. Fractures have been recorded in 55% of young children who have been abused and often are occult in young children who are unable to give a history (Kemp et al., 2006).

The standard skeletal survey imaging protocol developed by the American College of Radiology and recommended by the American Academy of Pediatrics (AAP) includes anterior/posterior views of the humeri, forearms, hands, feet, femurs, and lower legs, anterior/posterior view of the thorax and pelvis, lateral views of the thorax, lumbar spine, cervical spine and skull, as well as the frontal view of the skull (AAP, 2000). When abuse is strongly suspected, the standards recommend the procedure be repeated 2 weeks after the initial study to determine the age of individual injuries (AAP).

3. Is There a Particular Type of Referral that Should Be Made in a Case Like This?

Nonaccidental injury inflicted by caregivers is a leading cause of morbidity and mortality in children. Often, the initial injuries caused in children of abuse are soft tissue and/or skeletal fractures (King, Kiesel, & Simon, 2006). Questions to pose when obtaining a history should include how, when, where, and what caused the injury. The NP also should inquire about who witnessed the injury and determine whether the child has had previously recorded injuries. Most importantly, questioning if the injury is consistent with the development of the child is imperative (Oral, Blum, & Johnson, 2003). The diagnosis and treatment of a child with suspected child abuse should be approached in a multidisciplinary way. A complete understanding of appropriate referrals is necessary when caring for a potential child maltreatment victim. In the United States, individual states have specific professionals who are deemed mandated reporters. The mandated reporters have a legal and ethical duty to report cases of suspected child abuse to the individual state department of children and family services.

4. What Responsibilities, if Any, Do You Have to a Child with This Type of Injury and Diagnosis?

The responsibility of the NP is twofold: to maintain the safety and well-being of the child, and secondly, to inform the family that an investigation may need to be carried out because child maltreatment is a consideration. Parents should understand the investigation is necessary for the safety of the child. The emphasis of the discussion must be nonaccusatory and focused on the well-being of the child. Reactions of a parent may range from appreciation, hysterical denial, or violence. These types of reactions are common, and the NP should have the appropriate safeguards established prior to discussing this type of referral.

As an organization committed to improving the health care of children, the National Association of Pediatric Nurse Practitioners (NAPNAP) believes that a concerted effort must be made to prevent child maltreatment and/or identify and intervene in the early stages in a way that causes the least trauma to the child (NAPNAP, 2007). Pediatric nurse practitioners who work with children are in a strategic position to assess for the presence of risk and protective factors as well as provide primary prevention interventions. Child abuse, a serious life-threatening condition that occurs in all ages, races, and socioeconomic situations, is preventable. Pediatric health care providers have a responsibility to be alert to possible abuse and to provide a safety net for all children they care for.

C.R.'s arm was placed in a cast at a local emergency department, and his follow-up care was performed by a pediatric orthopedist. His case was reported to the Department of Children Protective Services. His family understood the need for referral and complied with the investigation. This child's sibling reported later to the investigators that he had pushed his brother off the couch. C.R. did not have a skeletal series done because his brother had confessed to pushing him. The child has had no further suspicious injuries and was doing well at the time of follow-up.


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