PUID: 63 || PLAB 2 Mock 6 :: ChildAbuse1: Boyfriend NAI

examiner mla
4 days ago
2 min read

Summary

This scenario involves a 4-month-old infant presenting with a spiral fracture, raising concern for non-accidental injury (NAI). The focus is on safe clinical assessment, safeguarding, escalation, and avoiding assumptions.

Key Points

Clinical Presentation (Orthopaedics / Paediatrics)

Spiral fracture in an infant → highly suspicious injury
Mechanism: requires twisting force, uncommon in accidental injury
Associated with possible abuse or safeguarding concern
Must consider:
- Trauma / fall history
- Bone disorders (e.g., osteogenesis imperfecta)
- Bleeding disorders

Safeguarding & Risk Assessment

Never make assumptions about cause or perpetrator
Focus on:
- Who was caring for the child
- Timeline of events
- Family dynamics
Assess:
- Biological vs non-biological caregivers
- Home environment
- Any history of violence or criminal background (indirect questioning)

Professional Responsibility

As an FY2:
- Do NOT make independent safeguarding decisions
- Escalate immediately to seniors
Follow legal safeguarding protocols
Duty aligned with GMC Good Medical Practice:
- Protect vulnerable patients
- Act on concerns promptly

History Taking Essentials

Presenting complaint:
- Onset, duration, progression of swelling
- Pain, irritability
Mechanism:
- Any fall or trauma
Supervision:
- Who was caring for the child at the time?
Social history:
- Caregivers, relationships, employment
Past history:
- Birth history
- Development
- Vaccinations
- Previous injuries
Red flags:
- Behavioural changes (fear, irritability, withdrawal)

Exploring Non-Accidental Injury (NAI)

Use indirect, non-accusatory questioning
Example:
- “Can you tell me who usually looks after Timothy?”
- “Has anything unusual happened recently?”
Avoid statements like:
- “Could it be your boyfriend?” ❌

Important Considerations

DO NOT make assumptions (critical error)
Always:
- Escalate to seniors
- Involve safeguarding team
- Document thoroughly
Maintain:
- Neutral tone
- Child safety as priority
Admission required until safeguarding clearance

Diagnostic Approach

Initial Assessment
- ABCDE (if acute)
- Pain assessment
Focused History
- Injury mechanism
- Timeline
- Caregiver details
Examination
- Full physical exam (look for:
  - Bruises
  - Multiple injuries
  - Signs of neglect)
Investigations
- X-ray (confirm fracture)
- Skeletal survey (if NAI suspected)
- Blood tests:
  - Coagulation profile
  - Bone profile
  - Genetic testing if indicated
Safeguarding Assessment
- Multidisciplinary team involvement

Management

Immediate

Admit child to hospital
Provide adequate analgesia
Immobilise fracture

Specialist Input

Orthopaedic referral:
- Casting vs surgery
Paediatric review

Safeguarding

Inform:
- Seniors
- Safeguarding team / social services
Legal obligation to report
Do NOT discharge until cleared

Documentation

Record:
- Full history
- Exact words used by caregiver
- Examination findings
- Actions taken
Essential for legal purposes

Follow-Up

Review in ~2 weeks
Ongoing safeguarding input

Communication Skills

Use:
- Calm, non-judgmental tone
- Simple language
Key phrases:
- “My responsibility is to ensure Timothy’s safety”
- “We need to involve specialists to understand this better”
Avoid:
- Blame or accusations
Show empathy:
- Acknowledge distress
- Allow questions
Maintain eye contact, supportive body language

📌 Avoid over-rehearsed phrases and artificial empathy

Ethical Considerations

Child protection overrides confidentiality
Duty of care:
- Protect vulnerable child
Maintain:
- Professional integrity
- Non-judgmental approach
Follow safeguarding laws and GMC guidance

📚 Additional Resources

GMC: Good Medical Practice (Safeguarding duties)
PLAB 2 Examiner Top Tips
GMC Examiner Common Errors Guide