Review Question - QID 219908

Pediatric Abuse Treatment Nonoperative QID: 219908 (SBQ24SM.44)

QID 219908 (Type "219908" in App Search)

A 3-year-old child presents to the emergency department with her mother. The mother reports that the child has been refusing to walk since picking the child up from daycare the previous evening. The mother cannot identify a clear injury that occurred. During the physical exam, the child refused to bear weight on the right lower extremity. The patient also withdraws when her right pant leg is elevated to evaluate the skin over the thigh and leg. The patient has bruises in multiple stages of healing along the bilateral extremities and along the pinna of the ear. There is also a circular 3 mm healing burn on the left thigh. A skeletal survey was completed, and it was negative for additional injuries. Figure A demonstrates right tibia AP and lateral plain films. Which of the following is the most appropriate next step?

Type & Select Correct Answer

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Application of a right long leg cast with 2-week outpatient follow-up

3/571

Application of a right short leg cast with 2-week outpatient follow-up

1/571

Allow the patient to be weightbearing as tolerated with repeat clinical examination in 2 weeks

6/571

Contact the child’s daycare to gather additional information

8/571

Contact the state child protection services team

96%

548/571

Select Answer to see Preferred Response

This patient presents with a nondisplaced spiral fracture of the right tibia with refusal to bear weight, which is a common accidental injury in the toddler age group. However, the patient also has skin injuries that raise a reasonable suspicion of abuse. Physicians are mandatory reporters to the state if there is a reasonable suspicion of child abuse.

Pediatric abuse is the second most common cause of death in children. The most common presenting exam finding in pediatric abuse is skin lesions. Pinna ecchymosis (Illustration 1) and suspected cigarette burns are highly specific for nonaccidental trauma. Several fracture patterns including metaphyseal corner fractures, bucket-handle fractures, and rib fractures have been published as specific for child abuse. However, the patient’s overall clinical presentation must be considered when evaluating for abuse. Child abuse mandatory reporting laws only require a physician to have a reasonable suspicion of nonaccidental trauma. Reports made in good faith are immune from legal liability.

Dr. Sullivan published his expert opinion on child abuse and the legal system. The author highlights that although physicians may have legal immunity when reporting in good faith, false positive reports cause significant familial, financial, and legal stress. The author concludes that the reporting orthopedic surgeon should be accurate in their evaluation and documentation.

Sheena et al. published a review article in 2020 regarding the role of an orthopedic surgeon in the identification and management of pediatric nonaccidental trauma. The authors review risk factors and common presentations of abuse. The authors conclude that an orthopedic surgeon has a moral and legal responsibility to report any reasonable suspicion for non-accidental trauma.

Figure A shows the AP and lateral plain films of a skeletally immature patient with a subtle nondisplaced right tibia fracture. Illustration 1 shows pinna ecchymosis.

Incorrect answers:
Answers 1-3: The most appropriate next step is to address the reasonable suspicion of non-accidental trauma. Outpatient follow-up is an inappropriate course of action.
Answer 4: The patient’s physical exam produces a reasonable suspicion of non-accidental trauma. An orthopedic surgeon does not need to establish a cause of injury to report to child protection services.

ILLUSTRATIONS: