What is the appropriate management for an 11‑month‑old infant who presents with a radial and ulnar fracture after a 2‑day delay following a fall on an outstretched hand, with no bruising or other injuries noted?

Management of an 11-Month-Old with Radial and Ulnar Fracture After Delayed Presentation

Treat the child immediately AND inform the appropriate child protective authorities (Option A). This case presents multiple red flags for non-accidental trauma that mandate both medical treatment and mandatory reporting.

Critical Red Flags for Abuse in This Case

This presentation raises significant concern for physical abuse based on several key factors:

• Age-specific high risk: An 11-month-old infant with radius and ulnar fractures falls into the highest-risk category for abuse, as fractures of the radius and ulna in children <1 year of age should be considered suspicious for abuse 1
• Delayed presentation: The 2-day delay in seeking care for a non-ambulatory infant with obvious functional impairment (not moving the hand) is highly concerning 2
• Mechanism inconsistency: Falls on outstretched hands (FOOSH injuries) are uncommon mechanisms in 11-month-old infants who typically lack the motor development and protective reflexes for this injury pattern 1
• Parental explanation inadequacy: The parents' reasoning that they "didn't see bruises" demonstrates poor recognition of injury severity or possible concealment 2

Mandatory Evaluation and Reporting

Immediate Medical Management

Complete skeletal survey is necessary for this infant 1:

• Guidelines establish that skeletal survey is necessary in children 0-11 months old with long-bone fractures regardless of history, with only two specific exceptions (distal radius/ulna buckle fracture or toddler fracture in 9-11 month-olds with reported fall while cruising/walking) 1
• This case does not meet either exception—both radius AND ulna are fractured, and the mechanism is inconsistent with developmental stage 1
• Skeletal survey detects occult fractures in 11-20% of infants undergoing abuse evaluation 1

Neuroimaging should be obtained despite absence of neurologic symptoms 1, 3:

• CT head without contrast is indicated, as 27-29% of infants <12 months with apparently isolated injuries have occult intracranial pathology 1
• Children <12 months may have significant intracranial injury without signs, symptoms, or retinal hemorrhages 1
• The ACR recommends head CT for children <24 months when physical abuse is suspected, even without clinical suspicion of intracranial injury 1

Legal and Ethical Obligation to Report

Healthcare providers must report concerns to child protective services 1:

• The American Academy of Pediatrics explicitly states that "all health care providers should be alert to signs of potential abuse when evaluating injured children and should report concerns to the appropriate authorities" 1
• This is a mandatory reporting situation, not optional 4, 5
• Reporting protects the child from escalating abuse—infants often present multiple times with abusive injuries before diagnosis, and sentinel injuries can precede more significant trauma 2

Why Other Options Are Inadequate

• Option B (Believe parents and treat): Fails to recognize abuse red flags and violates mandatory reporting requirements 1
• Option C (Treat and order head CT only): Incomplete—omits skeletal survey and mandatory reporting to authorities 1
• Option D (Call police): While law enforcement may become involved, the primary reporting obligation is to child protective services, not police 1

Clinical Pathway Implementation

The appropriate sequence is:

1. Stabilize and treat the fractures orthopedically
2. Complete skeletal survey to identify occult fractures 1
3. Obtain CT head without contrast to evaluate for occult intracranial injury 1, 3
4. Consult child protection team if available at your institution 4, 5
5. Report to child protective services as mandated by law 1
6. Document thoroughly all findings, inconsistencies, and concerns 4

Common Pitfalls to Avoid

• Do not be reassured by well-appearing children or well-nourished status—these factors do not exclude abuse 1, 2
• Do not accept parental explanations at face value when mechanism is inconsistent with developmental stage 1
• Do not delay reporting while gathering "more evidence"—suspicion alone triggers mandatory reporting 1
• Do not skip skeletal survey based on "normal" appearance elsewhere—occult fractures are common 1