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 Orthopaedic Encounter

Orthopaedic surgeons evaluate injured young infants and children in a variety of care settings, from the outpatient office to the adult or pediatric emergency department (ED) with nonuniform clinical and multidisciplinary team (MDT) resource availability. Although detailed history gathering and physical examination (PE) performance should be the same across care settings, imaging, laboratory testing, reporting to child welfare, and discharge from care vary based on the age of the child and the care setting. Infants are at the highest risk of abuse and warrant the most extensive NAT evaluation for occult injury often necessitating transfer to an ED or hospital skilled in treatment of trauma victims. Infants and children with fractures undergoing evaluation for NAT may require hospital admission based on severity of injury or pending a safe discharge plan determined by child welfare. In some care settings, MDT resources such as a skilled social worker, forensic nurse examiner, or Child Abuse Pediatrician (CAP, a pediatrician with subspecialty training in abusive injuries, an American Board of Pediatrics board–certified subspecialty since 2009) may be available to assist with care of the NAT victim. The following suggested approach accounts for variation in presentation by age, care setting, and resource availability.


A thorough history should be gathered both from the caretaker and, if developmentally appropriate, from the child in isolation in a nonaccusatory, nonleading manner, allowing for detailed narrative responses without interruptions; asking clarifying questions can be helpful.[9] The caregiver providing the history may or may not be the perpetrator of NAT. Table 2 delineates the key points to address in the history of present illness, medical history, and family history, including accurate medication use and any concerns for inherited bone fragility, connective tissue, or genetic disorders.

Mechanism of injury should be thoroughly documented; if no history of trauma is provided to account for the fracture, it is important to specifically ask whether trauma occurred and document denial of trauma.[9] The caregiver should be asked about concerns for NAT causing or contributing to the child's injury. Historical indicators of NAT are listed in Table 3.

Documenting developmental history is critical,[19] and when possible, developmental status should be assessed by direct observation.[19] Bony injury due to NAT decreases markedly among ambulatory children with more sophisticated mobility.[7] Therefore, diagnosis of a fracture in an infant or young child whose developmental status is incompatible with the identified injury suggests that NAT is the likely etiology.

Social history allows for assessment of psychosocial risk factors, as listed in Table 1, which may place an infant or child at a higher risk of NAT.[19,20] Although best assessed by a skilled social worker, when unavailable, the orthopaedic surgeon should at a minimum assess safety risks, such as intimate partner violence (which often co-occurs with child physical abuse[21]) or drug exposure (which often co-occurs with abuse and neglect). Considered risk factors for NAT, psychosocial factors are not strong determinants,[22] and NAT detection necessitates avoidance of stereotyping.

Physical Examination

A focused PE may result in a missed NAT diagnosis; comprehensive examination is vital. PE should be performed with the infant/child undressed in a gown[9] and before cast placement, examining for pain, altered mental status, cutaneous injury, other bony trauma, or occult head and abdominal injury. General inspection of the head, eyes, ears, nose, throat, skin, abdomen, and extremities is crucial for identification of NAT. Physical and behavioral signs of trauma are listed in Table 4.

Documentation of injuries with location, size, color, and shape of the injury is crucial;[9] photodocumentation of injuries should be strongly considered, either by the orthopaedic surgeon or by a skilled MDT member (forensic nurse or CAP). Skin injuries in unusual locations (such as the pinna [Figure 1], back of the ear, buttocks, and thighs) or with unusual patterns (such as stocking glove or the shape of an object [Figures 2 and 3]) should be noted. Skin injuries are the most common and readily visible injuries due to NAT but are missed as sentinel injuries in almost half of fatal and near-fatal injuries.[23] Tenderness to palpation of the chest/abdomen or abdominal distension should be noted, and careful palpation of the legs, arms, feet, hands, ribs, or head may reveal acute or healing fractures.[9] Abnormalities involving other organ systems may be indicative of additional occult NAT, meriting further evaluation including head or abdominal imaging and serum laboratory studies.

Figure 1.

Photograph showing pinna ecchymosis.

Figure 2.

Photograph showing patterned iron burn on the thigh.

Figure 3.

Photograph showing loop imprint on the thigh.

Diagnostic Imaging and Laboratory Studies

Imaging studies aid in the diagnosis of NAT. Fracture patterns with high specificity for NAT are sustained by mechanisms associated with NAT including high-energy scapula, spinous process, sternal, metaphyseal corner, and rib fractures, especially posteromedial and lateral rib fractures.[24] Anteroposterior compression of the chest levers the posterior ribs over the fulcrum of the transverse process causing posteromedial and lateral rib fractures[25] (Figure 4). Metaphyseal corner fractures (Figure 5) are Salter-Harris II fractures where the "Thurston-Holland" fragment can, depending on the angle of the radiograph, appear like a "corner" or "avulsion" fracture; these fractures result from shearing mechanisms secondary to flailing of the extremity (such as during abusive shaking of the body), yanking, or using the extremity as a lever. Transphyseal distal humerus, vertebral body fractures, digital fractures, complex skull fractures (Figure 6), bilateral or multiple fractures, and fractures in different stages of healing are of moderate specificity for NAT.[24] Although common, current AAOS guidelines support consideration of NAT when femoral shaft fractures are detected in children younger than 3 years.[26] Detection of injuries without known mechanisms, or histories inconsistent with healing characteristics visible on imaging, also supports concerns for NAT.

Figure 4.

Radiograph showing posteromedial rib fractures.

Figure 5.

Radiographs showing classic metaphyseal lesion: AP and lateral views of the right distal femur.

Figure 6.

Cranial fracture: cross-table radiograph and 3D reconstruction.

Skeletal survey (SS) (Table 5) is a powerful adjunct to the diagnosis of occult injury in a young or noncommunicative child by demonstrating occult fractures and their stages of healing (Table 6). The AAP considers SS a mandatory component of the evaluation of a suspicious injury in any child younger than 2 years[9] and recommends this study be repeated in 2 to 3 weeks to assess for healing of non- or minimally displaced injuries (such as rib fractures) or better distinguish normal variants from healing injuries.[27] Yield of SS decreases as children become more independently mobile; therefore, performance in children older than 2 years is based on clinical discretion[9] but could be considered in cases in which a child is nonambulatory, neurologically devastated, medically complex, or afflicted with an underlying bone fragility disorder. Repeat imaging with nuclear bone scan can identify new findings in more than 10% of cases; however, it is waning in use and is not recommended as a substitute for the initial SS.[28] Newer modalities including low-dose CT chest imaging can increase the diagnostic sensitivity for rib fractures better than repeated SS.[29]

Current AAP guidelines[9] recommend concurrent use of SS with advanced imaging and clinical examination to evaluate for occult injury in the head and abdomen and other forms of abuse (ie, sexual abuse and neglect). Head injury is the leading cause of death from NAT in children younger than 2 years,[30] and abdominal trauma is the second. Although abdominal trauma related to NAT is seen in all age groups, the peak incidence of severe and fatal NAT abdominal injuries is in toddlers.[31]

Both CT and MRI are acceptable diagnostic imaging modalities to assess NAT victims with possible associated head injury.[30] Emergent evaluation of head trauma in symptomatic infants or children should include noncontrast CT of the head with 3D reformatted images of the calvarium for evaluation of intracranial bleeding and skull fracture[32] and the benchmark full-sequence MRI of the brain and cervical, thoracic, and lumbar spine as soon as possible.[32] MRI better demonstrates anatomic detail, cortical contusions, parenchymal lesions, shear injuries, and hypoxic ischemic insults, permits aging/dating of head injury, and may predict neurologic recovery or developmental delay/deficits. Bony spinal injuries are rare; however, MRI demonstrates ligamentous injuries in almost 80% of patients with known NAT-related head trauma in stark contrast to accidental head-injured patients.[33]

Universal screening is recommended for occult head injury in neurologically asymptomatic infants younger than 1 year with any high-risk criteria (ie, rib fractures, multiple fractures, facial injury, and age less than 6 months[27]), and clinicians should have a low threshold for neuroimaging when NAT is suspected in a young child.[30] Children younger than 2 years are considered at a highest risk of head trauma.[30] Additional studies are required to guide age-appropriate use of neuroimaging tests; liberal screening is recommended.

Liver and pancreatic enzyme tests (ie, aspartate aminotransferase, alanine aminotransferase, amylase, and lipase) and urinalysis are helpful in diagnosing occult abdominal trauma in suspected NAT victims; if abnormal, CT of the abdomen/pelvis with IV contrast should be considered.[9] Tests for hematologic disorders should be considered in the setting of bruising.[9]

Bone health laboratory testing should be considered when fractures are identified; minimum recommended labs include calcium, phosphorus, alkaline phosphatase, vitamin D, and parathyroid hormone levels.[9] In special circumstances when concern for scurvy, copper deficiency, or osteogenesis imperfecta exists, serum copper, vitamin C, ceruloplasmin, or venous blood for DNA analysis (or skin biopsy for fibroblasts) can be considered.[9] Laboratory testing guidelines relate to injuries identified and differential diagnosis (Table 7 and Table 8).

Current guidelines from the AAP[9] lack age cutoffs for the use of imaging or laboratory testing in NAT screening; however, in general, the youngest infants (at the highest risk of abuse) should have the most comprehensive evaluations. Recommended utilization of studies is discussed in Table 9. Because additional diagnostic imaging and laboratory studies are routinely recommended for many suspected NAT victims, referral to the nearest ED may be appropriate, especially in circumstances in which an infant or child has additional injury detected or requires admission for treatment and/or safety planning (Table 6).

Differential Diagnosis

Table 7 and Table 8 define syndromes and nutritional deficiencies that should be considered in possible cases of NAT. Certain underlying conditions, such as bone fragility, can present similarly to NAT. While maintaining a strong suspicion for NAT, a broad differential diagnosis facilitates obtaining a correct and timely diagnosis of these conditions.

Children with chronic illness or neuromuscular disorders may have accompanying sarcopenia, poor nutrition, and inadequate calcium and vitamin D intake.[34] The bone of children with chronic diseases suffers a multimodal affront secondary to proinflammatory cytokines in inflammatory conditions, direct metastasis in hematologic and malignant conditions, disuse from chronic hospitalization or lack of ambulatory ability, and vitamin D deficiency due to lack of sunlight exposure secondary to photosensitivity from antibiotics or immunosuppressant medications. In addition, glucocorticoid treatment decreases bone formation, increases bone resorption, and induces sarcopenia.[35] Studies have shown an inverse relationship between skeletal muscle fat content and bone strength.[34] As there are a multitude of etiologies for osteopenia in the setting of chronic disease and disuse, management is similarly complicated. To adequately address osteopenia in these patients, it is important to address extrinsic factors, such as vitamin D and calcium deficiencies, as well as lack of exercise, where remediable, while addressing imbalances in bone resorption and deposition.