The Role of the Orthopaedic Surgeon in the Identification and Management of Nonaccidental Trauma

Sheena C. Ranade, MD; Abigail K. Allen, MD; Stephanie A. Deutsch, MD


J Am Acad Orthop Surg. 2020;28(2):53-65. 

In This Article

The Role of the Orthopaedic Surgeon

Fractures are the second most common injury caused by NAT after bruises.[6] Among infants and young children, 12% to 20% of fracture injuries are attributed to NAT.[7] As such, orthopaedic surgeons are at the frontlines providing care for suspected victims of NAT. Although accidental trauma is more common than abuse, maintenance of a high index of suspicion is critical to ensure that fractures due to NAT do not evade detection. As many as 20% of fractures in children younger than 3 years due to NAT are misdiagnosed or attributed to other causes, including medical diseases or underlying conditions.[8] This failure to correctly attribute fractures secondary to NAT may result in risk of ongoing, even fatal harm to a child.[8]

Patient age, mobility, and fracture type should inform suspicion for NAT. Among nonambulatory infants, or young children with limited mobility, rib fractures, midshaft humerus or femur fractures, multiple fractures, and unusual fractures (scapula, vertebrae, sternum, or classic metaphyseal lesions of the long bones) as well as fractures without clear or reasonable mechanism of injury, or known cause of bony fragility, should include NAT in the differential diagnosis.[9] In one recent study, characteristics including age less than 1 year, identification of multiple fractures, corner fractures, transverse fractures, and having public insurance were all associated with increased reporting of injuries as NAT to child welfare;[10] disparities in reporting NAT to child welfare agencies based on minority race/ethnicity and socioeconomic status have also been described.[11] Risk factors related to NAT have been reported (Table 1); however, no fracture type or pattern is diagnostic of or pathognomonic for abuse and any fracture in any child of any age, race, or socioeconomic status may be due to NAT. NAT may also be misdiagnosed if caregivers provide inaccurate or false histories[12] or if radiologic studies are incorrectly interpreted.[13]

As an evaluator of young infants and children with bony injury, the orthopaedic surgeon is critically positioned to detect abuse, and it is essential that the orthopaedic surgeon has sound, general knowledge about NAT. Both the American Academy of Pediatrics (AAP)[9,14] and orthopaedic literature provide several clinical references to guide the orthopaedic surgeon in evaluating presentations suspicious for NAT.[15–17] However, feeling comfortable diagnosing NAT may not be uniform. Tenenbaum et al[18] found that although over 89% of orthopaedic surgeons surveyed felt that it was their responsibility to report fractures suspicious for NAT, orthopaedic surgeons generally could benefit from improved child physical abuse detection training.