Spiral fractures and transverse fractures of long bones also raise suspicion for NAT. Injury to the metaphysis of long bones, especially in nonambulatory children, is considered highly suggestive of child abuse. The classic metaphyseal lesion, called a “corner” or “bucket-handle” fracture, occurs when the extremity (usually the forearm) is pulled or twisted forcibly, or the child is shaken. X-ray will demonstrate a disruption of the metaphysis with lucency. As the developing ribs are flexible and difficult to break with minor injuries, a child with a rib fracture and no history of severe trauma, such as a motor vehicle crash or fall from a significant height, has a high likelihood of being a victim of child abuse. Skull fractures caused from accidental injury and abuse may have similar presentations. The history and mechanism are important to correlate with physical examination findings for potential inconsistencies.13
Case Conclusion
The child in this case sustained a type II supracondylar fracture. Orthopedic surgery was consulted, and the patient was taken to the operating room for closed reduction and percutaneous pinning. She was placed in a cast, and pins were removed at follow-up 4 weeks later. No residual pain or deficits remained, and she regained full function of her arm.
Dr Hewett is a pediatric emergency medicine fellow, College of Medicine, Medical University of South Carolina, Charleston.
Dr Titus is vice chair, pediatric fellowships, and fellowship director, pediatric emergency medicine; and an associate professor of pediatrics, Medical University of South Carolina, Charleston.