SPECIAL REPORT
Non-Accidental or Accidental Trauma - Maybe, Maybe Not?
By Larry B. Mellick, MD, MS, FAAP, FACEP, Professor of Emergency Medicine, Professor of Pediatrics, Department of Emergency Medicine, Medical College of Georgia, Augusta.
Emergency medicine physicians are vulnerable to being sued for failure to diagnose non-accidental trauma.1,2 Over the years, emergency medicine physicians and pediatricians have been sued many times for failure to recognize and report non-accidental trauma and vulnerable children. Unfortunately, there are a number of ways to go wrong when it comes to reporting child abuse, and there are three recognized liability issues: A liability for failure to report suspected abuse, liability for reporting suspected abuse and liability for unauthorized release of confidential information during the course of reporting. Unfortunately, there are a number of conditions and presentations which frequently occur as the result of an accident, but could just as easily have occurred as a result of non-accidental trauma or child abuse. In this article we review several tricky conditions where the cause could be either accidental or non-accidental and are problematic in the context of liability for failure to report suspected abuse.
Torn Labial Frenulum
The labial frenum or frenulum is an upper and lower lip midline tag of tissue that attaches the lip to the gingiva. Its role and purpose is not perfectly clear, but it apparently can cause orthodontic or periodontal problems. It has been associated with a diastema or a space between the adult teeth. When it is surgically released it is called a "frenectomy." However, tears of the labial frenulum are not an uncommon cause for children presenting to the emergency department. In one review, approximately 8% of the oropharyngeal injuries were frenulum tears.3 When injured, this area bleeds pretty freely. Even though labial frenulum tears may occur from accidental injury, it can also occur as a result of abusive mechanisms such as force feeding or "bottle jamming." Thackeray, in a 2007 article, described three infants with tears of the labial frenulum who later presented with child-abuse-related head injury. In all three cases the health care team missed an "an opportunity to potentially intervene and protect the child from more severe injuries."4 If the child is not ambulatory and thus vulnerable to falls that can have a degloving mechanism, strongly consider non-accidental trauma.
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When a child presents with this injury, it makes sense to stop and ask if the story fits, if there are other signs of child abuse or if the social dynamics seem conducive to non-accidental trauma. While the child shown in Figure 1 sustained her injury following a fall, the injury appearance is identical to that seen with non-accidental trauma. Unfortunately, one review of the literature looked at 104 articles since 1966 and came to the conclusion that they could not determine the sensitivity of the torn frenulum as a sign of non-accidental trauma.5
Long Bone Spiral Fractures
Emergency medicine physicians are well indoctrinated that when pediatric patients present with long bone spiral fractures that non accidental trauma must be a consideration. Both long-term experience of child abuse experts and supporting evidence would suggest that one must strongly consider non-accidental trauma in the context of spiral fractures of pediatric long bones.6,7 However, spiral fractures of the tibial are common long bone fractures in children that can be caused by child abuse but are more commonly accidental.
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Originally, the fracture was described in 1964 as a radiographically obscure distal, spiral tibial fracture occurring in ambulating toddlers 9 to 36 months of age.8 Subsequent and larger series have suggested that the fracture also occurs in older children, is frequently accidental, and is not radiology obscure.9-11 (See Figure 2.) The originally described toddler's fracture is now considered to be a subset of the Childhood Accidental Spiral Tibial (CAST) fracture.11 As reported in one retrospective study, patients with isolated spiral tibial fractures ranged in ages from 12 months to 94 months (7 years, 10 months) with a mean age of 50.7 months. In contrast to the original description of the toddler's fracture, only one-third of children classified with CAST fractures were younger than 36 months. And, most CAST fractures involved the distal half of the tibia, not just the distal third.11
The history associated with these injuries typically describes a relatively minor trauma. Unfortunately, the described history in the presence of a spiral tibial fracture often seems incongruent and this raises the specter of non-accidental trauma. However, several case series and a review of the literature would suggest that the condition is much more commonly accidental in origin.12,13 An animal model of an accidental spiral tibial fracture has also been described.14 Nevertheless, spiral tibial fractures in non-ambulatory children must be considered non-accidental trauma until proven otherwise.
In summary, emergency physicians and pediatricians can and have been sued for failure to diagnose and report non-accidental trauma. And, there are a number of conditions that have been associated with child abuse that can also occur accidentally. Frenulum tears and isolated spiral tibial fractures are two such conditions. When the child has not yet begun to ambulate or toddle, the fork in the road is pretty well marked. Non-ambulatory infants with these injuries are much more likely to have sustained the injuries as a result of non-accidental trauma, and the management decisions should include steps to protect the child from further injuries.
References
1. http://biotech.law.lsu.edu/cases/reporting/Landeros.htm
2. Marion County, IN Circuit Court, Case No. 49C01-0401-MI-92.
3. Marom T, Russo E, Ben-Yehuda Y, et al. Oropharyngeal injuries in children. Pediatr Emerg Care. 2007;23:914-918.
4. Thackeray JD. Frena tTears and abusive head injury A cautionary tale. Pediatr Emerg Care. 2007;23:735-737.
5. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1726658&blobtype=pdf.
6. Strait RT, Siegel RM, Shapiro RA. Humeral fractures without obvious etiologies in children less than 3 years of age: When is it abuse? Paediatrics 1995;96:677-671.
7. Shaw BA, Murphy KM, Shaw A, et al. Humerus shaft fractures in young children: Aaccident or abuse? J Pediatr Orthop 1997;17:293-297.
8. Dunbar JS, Owen HF, Nogrady MM, et al. Obscure tibial fracture of infants the toddler's fracture. J Canad Assoc Radiol 1964;15:136-144.
9. Mellick LB, Reesor K. Spiral tibial fractures of children: A commonly accidental spiral long bone fracture. Am J Emerg Med 1990;8:234-237.
10. Mellick LB, Reesor K, Demers D, et al. Tibial fractures of young children. Pediatr Emerg Care 1988;4:97-101.
11. Mellick LB, Milker L, Egsieker E. Childhood accidental spiral tibial (CAST) fractures. Pediatr Emerg Care 1999;15:307-309.
12. http://emj.bmj.com/cgi/content/full/23/6/473
13. http://www.bestbets.org/bets/bet.php?id=134
14. Mellick LB, Mellick DL. An animal model of the childhood accidental spiral tibial fracture. Letters to the Editors. Pediatr Emerg Care 2004; 20:864.
Over the years, emergency medicine physicians and pediatricians have been sued many times for failure to recognize and report non-accidental trauma and vulnerable children. Unfortunately, there are a number of ways to go wrong when it comes to reporting child abuse, and there are three recognized liability issues: A liability for failure to report suspected abuse, liability for reporting suspected abuse and liability for unauthorized release of confidential information during the course of reporting.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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