An 11‑month‑old infant presents with right ulna and radius fractures two days after a reported fall on an outstretched hand; the parents delayed seeking care and report no bruising, and the child appears well‑nourished, well‑dressed, with regular well‑baby visits. What is the most appropriate next step?

Treat the child and inform the authorities

In an 11-month-old infant with ulnar and radial fractures, regardless of the plausibility of the reported mechanism or the child's overall appearance, skeletal survey and mandatory reporting to child protective services are necessary. 1

Why This Case Mandates Reporting

Age-Based Guidelines Are Absolute

• For children under 12 months old, skeletal survey is necessary regardless of fracture type or reported history, with rare exceptions. 1
• The American Academy of Pediatrics guidelines establish that skeletal survey is appropriate and necessary in nearly all fracture scenarios for infants under 12 months, independent of the stated mechanism of injury. 1
• Children in their first year of life have the highest rate of abuse victimization at 23.1 per 1,000, making this the highest-risk age group. 1

Red Flags Present in This Case

• Delay in seeking care (2 days) is a significant red flag for inflicted injury. 2
• The reported mechanism (fall on outstretched hand) in an 11-month-old requires scrutiny, as developmental abilities must match the injury pattern. 3
• Both-bone forearm fractures from simple falls are uncommon in pre-ambulatory infants. 3

The Well-Appearing Child Does Not Exclude Abuse

• Well-nourished appearance and regular well-baby visits do not rule out abuse. 4
• Studies demonstrate that 20-25% of fractures in children under 12 months are attributable to abuse, but the true proportion is higher due to underrecognition. 1
• Orthopaedic surgeons underestimate abuse in over 28% of cases when compared to child protection specialists. 5

Required Actions

Immediate Clinical Management

• Treat the fractures appropriately with immobilization. 6
• Obtain a complete skeletal survey (approximately 20 radiographs including oblique rib views) to identify occult fractures. 1
• Consider head CT if there are any neurologic symptoms, as occult head injury is common in abused infants. 1

Mandatory Reporting

• Report to child protective services immediately—the legal standard is "reasonable suspicion," not proof of abuse. 1
• The combination of age under 12 months, fracture, and delayed care meets the threshold for mandatory reporting. 1
• Failure to report can result in children suffering additional morbidity and mortality from ongoing abuse. 1

Follow-Up Skeletal Survey

• Repeat skeletal survey in approximately 2 weeks can identify healing fractures missed on initial imaging in up to 12% of cases. 1

Common Pitfalls to Avoid

• Do not be reassured by normal appearance, good hygiene, or regular medical care—these factors do not exclude abuse. 4
• Do not accept parental explanations at face value in infants under 12 months with fractures—the developmental stage makes most injury mechanisms implausible. 1, 3
• Do not delay reporting while awaiting additional workup—reporting and treatment occur simultaneously. 1
• Incontrovertible proof is not required; reasonable suspicion based on age and injury pattern is sufficient. 1

Differential Considerations

• While osteogenesis imperfecta and metabolic bone disease should be considered, these do not preclude reporting, as the evaluation for abuse and medical causes proceeds in parallel. 1
• Biochemical testing for bone disorders may be indicated but should not delay child protective services notification. 1

The answer is A: Treat the child and inform the authorities. 1