What is the most appropriate next step for a child presenting with fractures and potential signs of abuse after a reported fall?

Management of Suspected Child Abuse with Fractures

Treat the child and inform the authorities (Option A) is the most appropriate next step. 1

Immediate Mandatory Reporting

The American Academy of Pediatrics mandates reporting to child protective services based on reasonable suspicion alone, not certainty. 1 This case presents multiple concerning features:

• Ulnar and radial fractures in a young child raise significant concern for abuse 2
• Delayed care-seeking is a classic indicator of abuse 3
• The explanation of "not noticing bruising" is inconsistent with the severity of bilateral forearm fractures 3

The reporting threshold is "reasonable suspicion" or "reasonable belief"—incontrovertible proof is not required by state statutes. 2 All 50 states mandate reporting when suspecting child abuse or neglect. 1

Why This Case Warrants Suspicion

Age-Specific Risk Factors

• Fractures in children under 2 years have abuse rates of 20-25% for those <12 months and 6-7% for those 12-23 months 2
• The true proportion attributable to abuse is higher due to frequent failure of recognition 2

Red Flags Present in This Case

• Delay in seeking medical care is one of five key indicators of physical abuse 3
• History incompatible with injury severity (claiming not to notice bruising from bilateral forearm fractures) 3
• Multiple fractures (both ulna and radius) increase suspicion 2

Required Clinical Actions

Comprehensive Skeletal Survey

Obtain complete skeletal survey immediately, as recommended for all children <2 years with suspected abuse 2, 1

The skeletal survey should include:

• Frontal and lateral skull views, lateral cervical and thoracolumbar spine, single frontal views of long bones, hands, feet, chest, and abdomen 2
• Oblique rib views to detect rib fractures, which are strong predictors of abuse and may be the only skeletal manifestation 2
• Repeat skeletal survey at 2 weeks if initial findings are abnormal or equivocal, as this detects additional fractures in 9-12% of cases 4

Head Imaging Considerations

Consider head CT for any child <1 year with fractures suspicious for abuse, as brain injuries are often occult 2

• 29% of abused children without clinical suspicion of intracranial injury had positive neuroimaging (subdural hematoma, epidural hematoma, or cerebral edema) 2
• Most were <12 months of age with negative skeletal surveys and no retinal hemorrhage 2
• Unenhanced CT is the examination of choice for initial evaluation of intracranial injury 2

Evaluation of Household Contacts

Evaluate all siblings and household members <2 years for maltreatment 1

• 37% of households had all siblings affected and 20% had some siblings affected by maltreatment 1
• Siblings are at higher risk when the index child suffered moderate or severe maltreatment 1

Why Other Options Are Incorrect

Option B (Believe the relative and treat) is inappropriate because:

• The history is inconsistent with the injury severity 3
• Delayed care-seeking is a red flag 3
• Failure to report can result in ongoing abuse with increased mortality risk 5

Option C (Treat and order head CT only) is incomplete because:

• It fails to fulfill mandatory reporting requirements 1
• While head CT may be indicated 2, reporting to authorities is the priority action

Option D (Call the police directly) is not the standard approach because:

• Reports should go to child protective services first 1
• Police involvement occurs through the CPS investigation process

Common Pitfalls to Avoid

• Do not wait for proof—report based on reasonable suspicion alone 1
• Do not let fear of damaging the family relationship prevent reporting, as child safety is paramount 1
• Do not assume well-nourished appearance and regular well-baby visits exclude abuse 2
• For complex cases, consult with a child abuse pediatrician before deciding whether to report 2, 1

Documentation Requirements

Document all findings thoroughly, as this may be used in legal proceedings 1

Include:

• Detailed injury description and measurements
• Exact caregiver statements about mechanism
• Timeline of when injury occurred versus when care was sought
• All physical examination findings
• Complete skeletal survey results