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

Management After Diagnosis

Diagnosis of NAT may occur in any care setting; however, utilization of an MDT can optimize care. Skilled social workers, forensic nurses, and CAPS with additional training in the evaluation of NAT may provide ancillary opinions about fracture biomechanics and injury plausibility, recommendations for occult injury screening (including for at-risk contacts living in the child's home), and support consideration and testing for underlying bone fragility, genetic disease, or differential diagnoses. MDTs can facilitate reporting of NAT to child welfare and ongoing communication with investigators and provide needed testimony in medicolegal proceedings. If unavailable, the orthopaedic surgeon should consider consultation with a nearby children's hospital or larger medical facility with additional CAP-focused MDT resources either by telephone or through transfer.

Transferring care to another physician or medical facility does not negate the treating orthopaedic surgeon's mandated responsibility to report suspected NAT at the time concerns are recognized. The orthopaedic surgeon should still contact the appropriate authorities to report the suspected abuse. There is no requirement to determine the perpetrator or exact details of a traumatic event; however, reporting suspicion of NAT is considered compulsory to the diagnosis.[9] Once reported to child welfare, the orthopaedic surgeon should inform the child's caregivers that a report has been made using upfront, clear, and nonaccusatory communication framed in child safety. Ultimate decisions about case disposition (including, potentially, discharge home to the caregivers) are made by child welfare investigators and not determined by the orthopaedic surgeon, and the orthopaedic surgeon should feel comfortable communicating this to caregivers when notifying them of the report. Ideally, social workers and specialized MDTs are available to assist; however, the orthopaedic surgeon should be prepared to recognize NAT, initiate laboratory/diagnostic testing for occult injuries, and report concerns to child welfare services independently.

Hesitance to report NAT to authorities may occur for multiple reasons. Fear of disrupting the collegial patient-physician relationship[36] and possible malpractice suits or other legal entanglement may result in failure to report; orthopaedic surgeons may also have concern around NAT likelihood or feel pressured to have certainty. Reporting may also cause psychological distress to the reporter, as violence directed toward children can cause varied responses including sadness, rage, or secondary traumatic stress among those who detect it. Child abuse mandated reporting laws require only that orthopaedic surgeons have reasonable suspicion for NAT to meet the threshold of mandated reporting; certainty that an injury is NAT is not required. Reports made to authorities in good faith are immune from legal liability, whereas failure to report risks legal, civil, financial, and other licensure penalties.[15]

Once suspected NAT has been reported, the orthopaedic surgeon may be asked to provide information regarding the history, PE, and diagnosis to an assigned investigative caseworker from child welfare and/or law enforcement. Investigators will gather history from the caregivers and/or child directly, may perform a scene investigation (such as doll re-enactment) and/or depending on the level and nature of safety risks identified, take temporary custody of the child while further information is gathered. During this time, the child may require admission to the hospital for safety planning, be discharged to kinship care (temporary placement with other family members), or have a safety plan created by investigators to ensure temporary supervision of caregivers with the child. The orthopaedic surgeon should not discharge a child from care until indicated by the investigators to ensure the child's ongoing safety after medical care is complete.

The orthopaedic surgeon may be required to testify in either family court or criminal proceedings; the burden of proof for abusive injury in family court is a preponderance of the evidence, whereas for criminal court, the standard is beyond a reasonable doubt. When asked to testify, the orthopaedic surgeon should be prepared to discuss the details of the history, PE, and diagnosed injury and may be called upon to render an opinion regarding the mechanism of injury and abuse likelihood if qualified as an expert witness.