Case 24

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.

• David TJ. Avoidable pitfalls when writing medical reports for court proceedings in cases of suspected child abuse.. Archives of disease in childhood. 2004; 89 (9) : 799-804

  External Link • DOI • PubMed
  

  All paediatricians, paediatric radiologists, paediatric pathologists, forensic …

  All paediatricians, paediatric radiologists, paediatric pathologists, forensic pathologists, and many other specialists have to deal with cases of suspected child abuse, and in terms of the generation of complaints from families this is a high risk activity. Many complaints are devoid of merit, but in some cases a complaint is justified because of a faulty approach. This review draws attention to the avoidable pitfalls associated with report writing when child abuse is under consideration (see box 1).
• 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 (10) : 679-83

  DOI • PubMed
  

  Child Abuse Pediatrics (CAP) was recently approved as a new subspecialty by the …

  Child Abuse Pediatrics (CAP) was recently approved as a new subspecialty by the American Board of Pediatrics (Block & Palusci, 2006). Among the critical skills of the domain is the ability to collaborate and communicate effectively with social and legal professionals, including the writing of forensic reports. Reports written by child abuse pediatricians on children suspected of having been abused are intended to inform future medical care for the child and legal decisions related to the case, including court proceedings. Therefore, they need to be interpreted accurately not only by health care providers, but also by social workers, police officers and lawyers in the context of their investigations, as well as by lawyers, judges and juries in child protection or criminal proceedings. These reports should support their task of reaching a conclusion as to whether or not maltreatment is verifiable.