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Non-accidental trauma (NAT), or battered child syndrome, must be recognized
and reported by primary care physicians treating pediatric injuries. The
diagnosis of NAT is rarely straightforward. About 75% of abused children
are younger than 3 years of age. The consequences of failure to diagnose
NAT are significant, with a 35% risk of repeat injury and risk of death
up to 10%. Child abuse covers a broad spectrum, from emotional neglect
to physical injury.
Several patterns of fracture strongly suggest the diagnosis of NAT and
should prompt further investigation. Fractures highly suggestive of NAT
include multiple fractures in differing stages of x-ray healing, metaphyseal
corner fractures (those right next to the growth plate), spinous process
fractures (from getting hit on the back repeatedly), posterior rib fractures
(also from getting hit or shaken), complex skull fractures, and epiphyseal
separations. Spiral fractures involving the femoral diaphysis (mid-portion
of the femur) in a child younger than 12 months usually results from a
forceful twisting of the leg and should also prompt suspicion of NAT.
Physical findings must always be correlated with the history of the injury.
No single historical feature or behavior is consistently present in NAT.
Abusive parents rarely offer accurate information. Stepparents or boyfriends
are frequently implicated in documented cases. If the history is inconsistent
with the physical findings, it is best to ensure the safety of the child
and initiate further investigation into the circumstances of the injury.
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