What do I think?
1. I think it would actually be very difficult to tell if the 14 year old's fracture was not consistent with the mechanism of injury at this age. We can tell in infants with posterior rib fractures, metaphyseal fractures, or multiple fractures, fractures at varying ages of healing and certain long bone fractures in toddlers that these do or very likely do represent cases of non-accidental injury. In a 14 yr old girl, to determine if this fracture was non-accidental would generally be difficult unless it looked like a crush injury or something very serious. Most wrist fractures in a teen won't scream, "I am the result of abuse" and would more likely prompt an order for a vitamin D level. I don't even believe in most ED departments that with the history as written above, a CPS case report would even be initiated.
2. So a more important question might be, what could the ED do? Well first you want a good physical exam. In a 14 yr old with this hx, it would generally be inappropriate to completely undress and look at this child's entire body, but certainly she could take her shirt off (especially if in long sleeves or a turtle neck) so her shoulder and upper arm could be viewed for range of motion and other external indicators of other trauma such as bruising. Looking at her neck for signs of strangulation marks would be important and easy to do. Also looking at her arms for evidence of cutting would be important and would suggest something more serious is going on in this family.
3. Also some type of questionnaire for the patient (not just intake information for the family may be helpful). A simple questionnaire given to the teen about safety -- with just 4 yes/no questions could be useful. Along with a statement such as, in our ED we give this questionnaire to all teens who come in.
- Do you feel safe at home?
- Do you feel safe at school?
- Do you feel safe with friends?
- Do you feel safe in your community?
Having a means of asking these simple yes/no questions to the teen on a form that she can fill out without being required to verbally answer such questions in front of potentially punitive parents might just allow her to answer no to feeling safe at home and then the doctor could speak to her alone and ask why. This happened to me when I was 14. My dad punched me in the face and it cut my eyebrow (about 1 inch gash) and blackened my eye. My school teacher for the first time asked me what happened and guess what I said? "I fell". But if she had given me something to write on asking if I felt safe, I don't know for sure but I am certain there would have been a greater likely hood of my answering no to "Do you feel safe at home?"
So.....
I think this case, unless obvious non-accidental trauma occurred --- likely with multiple injuries or a significant complicated wrist fracture requiring surgery, wouldn't even prompt CPS referral and if it did would likely be "screened" out. 75 - 80 percent of CPS reports are screened out... meaning that they do not fit a definition where the state would believe an investigation is required. This occurs at least in Michigan.
Now the doctors could hospitalize her especially if she needed surgery on the wrist and not just casting and then they could get the hospital social worker involved and an astute and compassionate doctor could very likely get this girl to open up.
So what should CPS do? They most likely wouldn't be involved. What is more important is this. How can the doctors caring for this injured child have a greater "index of suspicion for abuse."
Actually there is one thing that CPS should do. That is accurately document a report. If in the future there were further reports, this makes it more likely that eventually an investigation would occur.
Thanks.