What is the most appropriate next step in managing an 11‑month‑old infant with right radial and ulnar fractures after a minor fall, delayed presentation, and no obvious bruising?

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

Treat the child's fractures immediately, perform a complete skeletal survey and head CT to screen for occult injuries, and report the case to child protective services—this combination of orthopedic stabilization, comprehensive imaging, and mandatory reporting is required for all infants under 12 months with long-bone fractures when the mechanism is developmentally implausible or presentation is delayed. 1

Why This Case Raises Suspicion for Non-Accidental Trauma

• Infants younger than 12 months with radius and ulna fractures are in the highest-risk category for physical abuse, and such fractures should be considered suspicious for non-accidental trauma 1
• A fall on an outstretched hand (FOOSH mechanism) is developmentally implausible in an 11-month-old who is not yet cruising or walking independently—this mechanism requires protective reflexes and motor coordination that most infants this age have not developed 1
• Delayed presentation of 2 days in a non-ambulatory infant with functional impairment further raises suspicion for abuse, particularly when the reported mechanism is inconsistent with developmental capabilities 1
• The absence of bruising does not exclude abuse—the majority of children with abusive fractures do not have associated bruising at the fracture site 2
• Well-nourished appearance and regular well-baby visits do not exclude abuse—appearance and prior healthcare engagement cannot be used as evidence against non-accidental injury 1

Required Imaging Evaluation

Skeletal Survey (Mandatory)

• The American Academy of Pediatrics mandates a complete skeletal survey for any child 0-11 months old with a long-bone fracture, except for isolated distal radius/ulna buckle fractures or toddler fractures in 9-11-month-old walkers with credible falls 1, 3
• This case does NOT meet the exceptions because both radius and ulna are fractured and the mechanism is inconsistent with developmental stage 1
• Skeletal surveys uncover occult fractures in approximately 11-20% of infants evaluated for possible abuse, most commonly rib fractures and metaphyseal injuries 2, 1
• The skeletal survey consists of approximately 20 radiographs including standard views and oblique rib images 3

Head CT Without Contrast (Mandatory)

• Non-contrast head CT is indicated for all infants <12 months with apparently isolated injuries because 27-29% have occult intracranial pathology 1
• Infants younger than 12 months may sustain significant intracranial injury without any neurologic signs, symptoms, or retinal hemorrhages 1
• The American College of Radiology recommends head CT for all children <24 months when physical abuse is suspected, regardless of clinical suspicion for intracranial injury 2, 1

Mandatory Reporting Obligation

• All healthcare providers must report any concerns of abuse to child protective services—this is both a legal and ethical obligation 1, 3
• "Reasonable suspicion" is the threshold for mandatory reporting, not definitive proof 3
• The combination of age <12 months, presence of fracture, and delayed presentation meets the threshold for mandatory reporting 3
• Reporting must occur before discharge and cannot be delayed while awaiting additional evidence or test results 1
• Failure to report can lead to additional morbidity and mortality from ongoing abuse 3

Clinical Management Algorithm

1. Immediate orthopedic stabilization of the radial and ulnar fractures 1
2. Complete skeletal survey to identify occult injuries 1, 3
3. Non-contrast head CT to evaluate for hidden intracranial injury 1
4. Consultation with the institution's child-protection team 1
5. Mandatory report to child protective services before discharge 1, 3
6. Consider metabolic bone disease workup (serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D) but do not delay reporting while awaiting results 2, 3

Critical Pitfalls to Avoid

• Do not accept parental explanations when the mechanism is developmentally implausible—an 11-month-old cannot generate the force or positioning for a FOOSH injury 1
• Do not rely on well-appearing status or good nutrition as evidence against abuse 1
• Do not delay reporting while pursuing differential diagnoses such as osteogenesis imperfecta—both the abuse evaluation and metabolic workup proceed concurrently 3
• Do not omit the skeletal survey based on normal physical examination elsewhere—occult fractures are common and cannot be detected clinically 1, 3
• Do not skip head imaging in the absence of neurologic symptoms—occult intracranial injury is present in over one-quarter of abused infants 1

The correct answer is A: Treat the child and inform the authorities. However, the complete management also requires skeletal survey and head CT as part of the comprehensive evaluation mandated for this age group and clinical scenario. 1, 3