NON – ACCIDENTAL INJURIES (NAI) and FRACTURE
In the context of fracture, suspect NAI if there is:
- Any fracture before walking age.
- Inconsistent history (i.e., the history 'doesn’t fit' the injury pattern).
- Inconsistent explanations (between parents / caregivers).
- Delayed presentation.
- Bruising patterns on the child.
- Long bone injury with head injury.
- Retinal haemorrhages.
- Unusual fracture patterns such as:
- Transverse fracture in long bone.
- Metaphyseal corner fractures / Bucket handle fracture also known as Classical Metaphyseal Lesion.
- Rib fractures (Posterior ribs or at costochondral junctions).
- Skull fractures (depressed skull fractures or non-parietal skull fractures).
- Fractures at varying stages of healing on skeletal survey.
Priority is to place the child in a safe environment (i.e., admit the child to the ward), inform child protection services and assess further to exclude life threatening injuries e.g., subdural haematoma, ‘shaken’ baby syndrome, blunt abdominal injuries.
- Bony injuries should be treated in the same principles as accidental injuries.
- A set of skeletal survey radiographs should be obtained in all suspected cases of NAI. A further sensitive way to diagnose NAI is Technetium 99m labelled Bone scan. However the radiation exposure is considerable and the decision has to be made on strong suspicion with appropriate involvement of paediatricians.
- The paediatric team should be involved early on to assess the milestones, nutritional status and social circumstances, to rule out sexual abuse and ensuring safety of the child.
- Differential diagnoses include skeletal dysplasias, Osteogenesis Imperfecta (type I), Rickets and birth injuries.
- Prompt diagnosis of NAI, can prevent further injuries to the child and in some extreme cases, prevents death.
Further information on when to suspect NAI and investigations are provided.