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Fracture type

The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.


  • The commonest fracture location in both abused and non-abused children children was mid-shaft of the femur 5-7,11-17
  • Proximal physeal injuries were noted in abused children 5,8,10,12
  • Impacted transverse fractures of the distal femoral metadiaphysis were noted to be non-abusive in 13/22 (72%) cases versus five (28%) abused cases. The mean age did not differ between the two groups (abuse eight months, non-abuse 12 months). This was a highly selected case series ascertained through child protection specialists 9
  • Diaphyseal fractures were more common in accidental than abusive injury (p=0.007) 3
  • Distal femoral fractures were more common in abused than accidentally injured children (p=0.01) 3

Femoral shaft fractures

  • Transverse femoral fractures were more commonly associated with abuse than accidental injury 11
  • No association between spiral fracture and abuse was confirmed with this population of children aged less than three years 11
  • Metaphyseal fractures were recorded in more abusive femoral fractures than non-abusive fractures 1,4,5,13,17
    • 10/20 complete distal femoral metaphyseal fractures occurring in children aged less than one year were due to abuse 2
    • Accidental causes of metaphyseal fractures included birth injury, motor vehicle collision and falls 2

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  1. Anderson WA. The significance of femoral fractures in children. Annals of Emergency Medicine. 1982;11(4):174-177 [Pubmed]
  2. Arkader A, Friedman JE, Warner WC, Jr., Wells L. Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age. Journal of Pediatric Orthopedics. 2007;27(7):751-753 [Pubmed]
  3. Baldwin K, Pandya NK, Wolfgruber H, Drummond DS, Hosalkar HS. Femur fractures in the pediatric population: abuse or accidental trauma? Clinical Orthopaedics and Related Research. 2011;469(3):798-804 [Pubmed]
  4. Barber I, Perez-Rossello JM, Wilson CR, Kleinman PK. The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatric Radiology. 2015;45(1):69-80 [Pubmed]

  5. Beals RK, Tufts E. Fractured femur in infancy: the role of child abuse. Journal of Pediatric Orthopaedics. 1983;3(5):583-586 [Pubmed]
  6. Blakemore LC, Loder RT, Hensinger RN. Role of intentional abuse in children 1 to 5 years old with isolated femoral shaft fractures. Journal of Pediatric Orthopaedics. 1996;16(5):585-588 [Pubmed]
  7. Dalton HJ, Slovis T, Helfer RE, Comstock J, Scheurer S, Riolo S. Undiagnosed abuse in children younger than 3 years with femoral fracture. American Journal of Diseases of Children. 1990;144(8):875-878 [Pubmed]
  8. Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. Journal of Pediatric Orthopaedics. 1992;12(2):164-168 [Pubmed]
  9. Haney SB, Boos SC, Kutz TJ, Starling SP. Transverse fracture of the distal femoral metadiaphysis: a plausible accidental mechanism. Pediatric Emergency Care. 2009;25(12):841-844 [Pubmed]
  10. Jones JC, Feldman KW, Bruckner JD. Child abuse in infants with proximal physeal injuries of the femur. Pediatric Emergency Care. 2004;20(3):157-161 [Pubmed]
  11. Murphy R, Kelly DM, Moisan A, Thompson NB, Warner WC Jr, Beaty JH, Sawyer JR. Transverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures are. The Journal of Bone and Joint Surgery. American Volume. 2015;97(2):106-111 [Pubmed]

  12. Ogden JA, Lee KE, Rudicel SA, Pelker RR. Proximal femoral epiphysiolysis in the neonate. Journal of Pediatric Orthopaedics. 1984;4(3):285-292 [Pubmed]
  13. Rex C, Kay PR. Features of femoral fractures in nonaccidental injury. Journal of Pediatric Orthopaedics. 2000;20(3):411-413 [Pubmed]
  14. Rosenberg N, Bottenfield G. Fractures in infants: a sign of child abuse. Annals of Emergency Medicine 1982;11(4):178-180 [Pubmed]
  15. Scherl SA, Miller L, Lively N, Russinoff S, Sullivan CM, Tornetta 3rd. Accidental and nonaccidental femur fractures in children. Clinical Orthopaedics and Related Research. 2000;(376):96-105 [Pubmed]
  16. Thomas SA, Rosenfield NS, Leventhal JM, Markovitz RI. Long-bone fractures in young children: distinguishing accidental injuries from child abuse. Pediatrics. 1991;88(3):471-476 [Pubmed]
  17. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. British Medical Journal (Clinical Research Edition). 1986;293(6539):100-102 [Pubmed]


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