Is a spiral tibial fracture in a 6-year-old child (six years old) at high risk for Non-Accidental Injury (NAI)?

Spiral Tibial Fracture in a 6-Year-Old: NAI Risk Assessment

A spiral tibial fracture in a 6-year-old child is NOT at high risk for non-accidental injury (NAI), as this age represents an ambulatory child where such fractures are predominantly accidental in etiology. 1, 2

Age-Based Risk Stratification

The critical determinant for NAI suspicion with tibial fractures is the child's ambulatory status and age:

• Children <12 months (non-ambulatory): Tibial fractures are highly suspicious for abuse and warrant skeletal survey 1, 3
• Children 12-18 months: Moderate suspicion depending on developmental milestones and mechanism 1
• Children >18 months (ambulatory): Tibial fractures, including spiral patterns, are most commonly accidental 1, 2

At 6 years old, this child is well beyond the high-risk age threshold, as 80% of abused children with fractures are <18 months of age. 1

Fracture Pattern Considerations

While earlier teaching emphasized that spiral fractures should always raise suspicion for abuse, current evidence refutes this:

• Spiral tibial fractures (toddler's fractures) are commonly accidental in ambulatory children, occurring from twisting mechanisms during normal play or falls 1, 2
• One series found 9 of 10 isolated spiral tibial fractures in young children were accidental, not abusive 2
• No single fracture pattern can distinguish abuse from accident with absolute certainty 1

The American Academy of Pediatrics explicitly states that spiral fractures are caused by torsional loading along the bone's long axis, which can occur during falls with leg twisting—a common mechanism in ambulatory children 1

What WOULD Raise Suspicion

Even in a 6-year-old, certain features should prompt NAI evaluation:

• Multiple fractures in different skeletal areas or at different healing stages 1
• Unexplained fractures or history inconsistent with injury mechanism 1
• High-specificity fractures: posterior rib fractures, classic metaphyseal lesions, scapular fractures, or complex skull fractures 1, 4
• Associated injuries: bruising patterns, other soft tissue injuries, or retinal hemorrhages 1
• Delayed presentation or changing history 3

Clinical Pitfalls to Avoid

Do not assume all spiral fractures indicate abuse—this outdated teaching has been superseded by evidence showing ambulatory children commonly sustain spiral tibial fractures from accidental mechanisms like falls down stairs with leg folding underneath 1

Do not miss genuine abuse indicators by focusing solely on fracture pattern: always obtain detailed mechanism history, document time interval between injury and presentation, perform thorough examination for other injuries, and assess developmental appropriateness of the stated mechanism 3

Document the mechanism thoroughly, as unclear or inconsistent history is a crucial red flag that was noted in high proportions of NAI referrals 3

Recommended Approach for This Case

For an isolated spiral tibial fracture in a 6-year-old:

• Obtain detailed history of injury mechanism (fall, sports, twisting during play) 1
• Perform complete physical examination looking for other injuries or bruising 1
• Assess whether mechanism is developmentally appropriate and consistent with fracture 1
• If history is clear, consistent, and appropriate for age, proceed with standard orthopedic management without NAI workup 1, 2
• Consider skeletal survey or child protection referral only if red flags present (inconsistent history, multiple injuries, developmental concerns) 1