The Role of the Orthopaedic Surgeon in the Identification and Management of Nonaccidental Trauma

Sheena C. Ranade, MD; Abigail K. Allen, MD; Stephanie A. Deutsch, MD


J Am Acad Orthop Surg. 2020;28(2):53-65. 

In This Article

Abstract and Introduction


Nonaccidental trauma (NAT) has short- and long-term effects on the patient. The importance of identification and management of injuries related to NAT can be vital to the disruption of patterns of abuse and can ultimately save lives. The purpose of this review is to educate the orthopaedic surgeon as the frontline provider in the treatment of these patients. Understanding the risk factors for abuse, sentinel signs on clinical examination, and questionable fracture patterns related to NAT enables providers to better identify and address children at risk of abuse or neglect. Equally as important, understanding pathologic states that can mimic NAT allows the orthopaedic surgeon the tools necessary to address all patients with multiple and/or unexplained fractures. Understanding the legal expectations and protections for practicing orthopaedic surgeons as mandated reporters and the importance of a multidisciplinary approach to intervention in these settings will improve patient experiences and outcomes.


Historically, the identification and diagnosis of fractures in young infants and children has raised concern for abusive, inflicted injuries, referred to as nonaccidental trauma (NAT). In the 1940s, radiologist John Caffey documented a case series of 6 infants with multiple fractures in various stages of healing, including metaphyseal fragmentation, external cortical thickening, and subdural hemorrhage raising concern for NAT,[1] and in 1962, Kempe et al[2] coined the term battered child syndrome to define a condition in which young infants and children sustained serious physical injury from abuse by a caregiver.

Subsequently, The Child Abuse Prevention and Treatment Act (Public Law 93–247) was enacted in 1974 as key federal legislation addressing NAT, defined at a minimum as "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm." Each state sets standards and definitions of child abuse and neglect based on federal law, but all 50 states, the District of Columbia, and US territories have reporting laws that mandate certain professionals, including orthopaedic surgeons, refer suspected NAT to child welfare service.[3]

This continuing public health crisis resulted in 4.1 million referrals to child welfare agencies alleging maltreatment involving 7.5 million children in 2017 alone; 674,000 children were confirmed victims of abuse or neglect, including 1,720 fatalities.[3] Infants younger than 1 year are at a highest risk of abuse, victimized at a rate of 25.3 per 1,000 children and accounting for most NAT-related fatalities.[3] Most abuse perpetration involved biological parents, deflating commonly held notions about "stranger danger."

Child abuse-related statistics are likely underreported; the true prevalence of NAT is likely markedly greater because of underdetection. Adverse effects of NAT have lifelong ramifications including poor long-term physical and mental health outcomes, permanent disability, and even earlier death,[4] which in turn affects society[5] through increased healthcare costs, lost wages, and reduced productivity both among victims in adulthood and their families.