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Child Abuse Case 24


A 4-year-old boy complained of arm pain and was brought to the emergency department. There was no history of a fall or other injury. He lives at home with his mother and was recently in the care of his mother’s boyfriend while she was out of town. The radiograph below indicates the finding of a nightstick fracture of the ulna.

You have reported this finding to child protective services, but they are unaware of the significance of the injury. When you explain your concerns, they ask you to put your concerns in writing.



Case 24


You write a brief note to the child protective worker that includes which of the following formulations?

  1. In my opinion, this child (name here) has suffered from non-accidental trauma. The ulna fracture, also called a nightstick fracture, is suspicious for a direct blow to the arm.
  2. This child has a nightstick fracture, and it is suspicious for child abuse.
  3. The finding of a fracture without a history of accidental fall confirms that child abuse occurred.
  4. The finding of a nightstick fracture was likely caused by the mother’s boyfriend.

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The answer is A.

A nightstick fracture is an isolated fracture of the ulna associated with a direct blow. Nightstick fracture is a descriptive colloquialism based on the mechanism of injury. When you defend yourself from an attacker wielding a stick (club, baseball bat, crowbar, etc.), you tend to protect your head by bringing up an arm(s) with your thumb pointing towards you (radial aspect) and your ulna presented to block the oncoming blow. This is the mechanism of injury for nightstick fracture. The nightstick fracture is usually described as an isolated fracture of the middle third of the ulna. In the absence of any other history of injury, this finding is suspicious for inflicted trauma.

Answer A provides a clear opinion and reason for this opinion. Answer B does not explain a nightstick fracture or why it is suspicious for abuse. Although C may be true, that is not the sole reason that the physician is suspicious for abuse in this instance and writing just this statement may be confusing to the non-medical reader. Answer D states that the perpetrator is the mother’s boyfriend. In general, assigning blame for the abuse is not within the realm of the medical provider, except in cases where safety is an issue. For example, if there is a suspicion that the caregiver has caused the injury, then the medical provider should take action to prevent further injury. Documenting the concern in the medical record is appropriate. However, specifically stating that the boyfriend caused the injury is beyond the role or expertise of the physician.

Child protective workers can do their job better if they have clear information from the medical community in the form of written documentation to support medical findings and assessments. In some cases, this can be written into the medical record or report and include a summary statement. However, the documentation may be needed prior to receiving the medical record, and because of hospital policies, it may be difficult to release the record if the child is still hospitalized. In addition, the opinions of medical professionals are usually not meant to be included in medical record documentation.

In order to provide the needed information in a timely manner, the medical professional can write a specific statement as an affidavit or as a letter, often called an "impact statement." This statement can inform, interpret, or provide an opinion for the police, child protective services or the court. It can also serve as a way to inform future medical care for the child and legal decisions related to the case, including court proceedings.

David (see reference below) suggests these documentation tips:

  • Avoid jargon
  • Create a written chronology of information
  • Describe the injury by stating facts and estimate degree of force
  • Avoid assignment of "intent"
  • Differentiate natural disease states
  • Differentiate accidental and non-accidental
  • Admit uncertainty
  • Consider pointing out limitations of the report

The following is a guide for developing an impact statement. Physical abuse, sexual abuse, emotional abuse or neglect situations may include one or more of the listed suggestions. In some cases, additional information not listed here may be required. If there is no concern for abuse or neglect, this format (with changes) may be utilized as a letter of support for the parent or guardian.

Introduction

  • Describe how you know the patient.
  • State the referral source and when you performed an examination or reviewed records.

Body

  • Provide the presenting complaint (brief history), describe the physical findings and define the medical issues. List tests performed, treatment given and what tests are pending. Describe the issues that cause concern.

  • For neglect situations, describe specific concerns such as missed medical appointments with provider/specialty clinics, non-compliance with medications, poor dietary intake despite counseling, etc.

  • Explain the usual mechanism for an injury and whether the history explains the finding. For neglect, discuss normal growth, development and expected parental responses or other effect, depending on the situation.

  • Make a statement regarding time frame since the abuse or neglect began.

Formulation

  • Give your opinion regarding the finding or the patient’s general well-being.

  • Explain what this opinion is based on (if you can say). Balanced objectivity is necessary but should support your opinion.

  • Each injury might best be described separately or under a separate heading.

  • Depending on the context, "suspicious for" is often less convincing than "consistent with" or "indicates." If you are unsure, "suspicious" allows for uncertainty. In the case of abuse, these words can be used, but to support the fact that an injury is non-accidental, words like "unusual," "highly unlikely to be accidental" or "indicates non-accidental injury" are more persuasive.

Summary Impact

  • Explain if the finding is severe or life threatening. Describe the risks due to complications.

  • For neglect, describe the negative impact of the parent’s inability or unwillingness to follow medical treatment for the child. This should include the range of medical risk factors.

References
David TJ. Avoidable pitfalls when writing medical reports for court proceedings in cases of suspected child abuse. Arch Dis Child. 2004; 89(9): 799-804.

Mian M, Schryer CF, Spafford MM, Joosten J, Lingard L. Current practice in physical child abuse forensic reports: A preliminary exploration. Child Abuse & Neglect. 2009;33:679-683.


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