From the Guidelines
Spiral fractures are concerning for non-accidental trauma (NAT), particularly in non-ambulatory children, but they are not diagnostic on their own. When evaluating a spiral fracture, healthcare providers must consider the child's developmental stage, the reported mechanism of injury, and whether the explanation is consistent with the injury pattern 1. Spiral fractures result from rotational forces applied to a bone and can occur accidentally in mobile children during falls or twisting injuries. However, in infants or children who cannot yet walk, or when the history provided doesn't match the injury severity, suspicion for abuse should be heightened.
Key Considerations
- The child's motor developmental level is a key discriminator for abuse in certain fractures, particularly femoral fractures in a child who is not yet walking and unexplained humeral fractures in children < 15 months of age 1.
- Additional concerning features include delayed medical attention, changing explanations for the injury, multiple fractures in different healing stages, or fractures in unusual locations.
- A thorough evaluation including a complete skeletal survey, detailed history, and examination for other signs of abuse is essential when NAT is suspected 1.
Evaluation Approach
- The assessment should be comprehensive but approached without presumption of guilt, as many spiral fractures do result from accidental mechanisms, especially in ambulatory children.
- Healthcare providers should be aware that falls are common in childhood and can cause fractures, but they rarely result in additional significant injury 1.
- The evaluation should consider the type of load that is necessary to cause a particular long bone fracture and whether it is consistent with the injury described by the caregiver 1.
From the Research
Spiral Fractures and Non-Accidental Trauma (NAT)
- Spiral fractures are one of the most common fractures seen in nonaccidental injury, as noted in a study published in the Journal of pediatric orthopedics 2.
- However, the presence of a spiral fracture does not always indicate NAT, as isolated spiral tibial fractures of childhood are most frequently accidental in etiology, according to a study in The American journal of emergency medicine 3.
- Transverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures, as found in a study published in The Journal of bone and joint surgery. American volume 4.
Factors Associated with Non-Accidental Trauma
- Age less than 1 year, multiple fractures, corner fractures, transverse fractures, and being covered by Medicaid are factors associated with reporting of NAT, as identified in a study in Journal of children's orthopaedics 5.
- The direction of the torsional force producing spiral fractures can be determined from characteristic features on routine anterior-posterior and lateral radiographs, which can aid in the assessment of NAT, as noted in the study published in the Journal of pediatric orthopedics 2.