You are here » CORE INFO » Reviews » Fractures » Which fractures are indicative of abuse? » Other useful references

Other useful references

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.


Rib Fractures


Imaging Strategies


  • The use of CT and US for visualising rib fractures is detailed here
  • Oblique views on chest X-ray of the ribs are significantly better at detecting posterior rib fractures 1
  • Posterior rib fractures may not be seen on a skeletal survey but identified at post-mortem 2



  • Rib fractures have been described as a consequence of chest physiotherapy for bronchiolitis in France 3, however a recent study of 647 children undergoing chest physiotherapy resulted in no rib fractures 4
  • The method of physiotherapy was not described and all children received this therapy unsupervised in their own homes 3

Femoral Fractures


  • There is a decrease in the incidence of femoral shaft fractures in children, reduction of 42% between 1987 – 2005 5
  • The commonest cause of femoral fracture in children less than four years of age is a fall of less than one metre 5
  • A fracture classification system to distinguish transverse, oblique or spiral fractures was developed and validated. There was moderate inter-observer reliability 6

Skull Fractures


  • Biparietal skull fractures might result from a single blow to the occiput, as described accidentally 7
  • An influential study of severely abused children stated that depressed, diastatic, growing, and multiple fractures were more common in abuse than in non-abuse. The study included a considerable number of fatally abused children, and was not eligible for inclusion in this systematic review 8


Tibial Fracture


  • Inadequate data on tibial fracture for meta-analysis 32
  • Undisplaced spiral fracture of the tibia without a concomitant fibular fracture is most likely to be a toddler fracture particularly if the child is a boy less than 2.5 years of age 32


Humeral Fracture

  • A case series of seven infants aged 4-7 months with isolated humeral fractures postulated to occur when the infant rolled over.  Skeletal surveys were negative, all cases arose as a consequence of court proceedings 9
  • Radiological identification of distal humeral epiphyseal separation is aided by the use of ultrasound in young infants 10

Metaphyseal Fractures


  • Metaphyseal fractures may be missed if appropriate radiology is not employed 11,12
  • Inappropriately administered physiotherapy, particularly to preterm infants, has caused metaphyseal fractures 13
  • Metaphyseal fractures are also recorded in serial casting of clubfoot 14
  • Birth trauma can cause metaphyseal fractures in breech delivery 15
  • External cephalic version for breech presentation may result in classic metaphyseal lesion (CML) 16
  • CML occurring following birth was associated with pain expressed in irritability, lack of spontaneous movement of the affected leg and poor feeding in an infant 16
  • A high resolution CT study defines the precise fracture plane that occurs in metaphyseal fractures, contributing to an understanding of the biomechanics of these fractures 17



  • Post-mortem CT has a low sensitivity for rib fractures in comparison to autopsy 18
  • Proposed autopsy techniques to maximise identification of fractures 19
  • It is proposed that cone-beam CT performed during post-mortem may aid in the dating of fractures 20
  • Vertebral clefts may be visible through the vertebral body and be confused with fractures. A post-mortem study discusses ten affected fetus’ 21

Important Clinical Differentials


  • Sternum ossification centres projected over ribs on a chest film mistaken for fractures. Follow up revealed real cause 22
  • Diffuse cortical thickening on the medial aspect of the tibia, mimicking periosteal reaction; may result from intraosseous needle insertion, but has been mistaken for abuse 23
  • An overview of clinical variants that are important on reviewing skeletal surveys 24
  • Heterotopic ossification from the ischium and sacrum to proximal femur posteriorly secondary to physical abuse 25
  • Metaphyseal fragmentation may be noted in infants, simulating metaphyseal fractures 26
  • It is important to distinguish normal suture variants within the occiput from fractures 27
  • An unossified membranous strip within the parietal bone may be mistaken for skull fracture in infants 28
  • Widespread medullary necrosis and periosteal reaction, with epiphyseal sparing, described as a complication of traumatic pancreatitis 29



  • Fractures determined by type and rates of stress and strain applied to a bone 30-34
  • Reviews of biomechanics highlight numerous variables relating to childhood fractures 30-34
  • Studies of falls down stairs highlighted that the peak age are children aged one year, sustaining predominantly minor injuries with 4/18 sustaining skull fracture and 10% with limb fractures 35


Consequences of Abusive Fractures


·         Compartment syndrome may occur in the lower limbs as a consequence of abusive fractures 36


Presenting Features


  • 21% of children with abusive fractures missed at initial presentation 37
  • Boys with extremity fractures attending non-pediatric emergency department or primary care most commonly missed 37
  • A Survey of orthopaedic surgeons in Israel identified that only 35% had received training regarding child protection 38
  • Delay (more than 8 hours) in presentation with an extremity fracture was evaluated in 206 children 39
  • Although the median time to presentation was one hour, 21% presented after 8 hours, 15% showed no external sign of injury and 12% used the injured extremity normally. However, all children had at least one sign or symptom 39
  • A study of children with OI showed that although 21% sustained rib fractures, none of these occurred in infancy. All children with two or more fractures had previously been diagnosed with OI 40

Birth related fractures


  • A study of birth related fractures, including metaphyseal, confirms that these fractures are painful and may be associated with tenderness and swelling 41
  • Multiple rib fractures described in macrosomic infant with shoulder dystocia 42,43
  • Posterior rib fractures described as birth injuries, some macrosomic 44,45 including those with shoulder dystocia 42,43
  • Classic metaphyseal lesions of the femur have been noted after caesarian section.  Two cases were breech presentation 46
  • Femoral fractures are a rare birth injury (incidence 0.13/1000) as recorded in Ireland between 1996 – 1999.  The typical fracture occurring was a spiral fracture of the proximal half of the femur which was held in an extended position. 5/7 affected infants were delivered by caesarean section.  In 6/7 cases, no evidence of femoral injury was noted on immediate post-natal examination 47
  • Birth injury can cause depressed skull fractures 48
  • Rib fractures have been identified in approximately 2% of ex pre-term infants (less than 37 weeks gestation) 49

 Age and likelihood of abuse


  • The relative risk for child abuse in children aged less than one year was 11.46; 3.07 for those aged 1-2 years 50
  • Abusive fractures more common in children less than 13 months of age 51
  • The proportion of fractures rated as abusive in children aged less than three years attending a single centre fell by up to 50% over 24 years 52


Click here to open


  1. Ingram JD, Connell J, Hay TC, Strain JD, Mackenzie T. Oblique radiographs of the chest in nonaccidental trauma. Emergency Radiology. 2000;7(1):42-46 [Abstract from Springer Link]
  2. Kleinman PK, Marks SC, Adams VI, Blackbourne BD. Factors affecting visualization of posterior rib fractures in abused infants. American Journal of Roentgenology. 1988;150(3):635-638 [Pubmed]

  3. Chalumeau M, Foix-l'Helias L, Scheinmann P, Zuani P, Gendrel D, Ducou-le-Pointe H. Rib fractures after chest physiotherapy for bronchiolitis or pneumonia in infants. Pediatric Radiology. 2002; 32(9): 644-647 [Pubmed]
  4. Chapuis A, Maurric-Drouet A, Beauvoisc, E. [La kinésithérapie respiratoire ambulatoire du nourrisson est-elle pourvoyeuse de traumatisme thoracique?] [French] Is the outpatient infant's chest physiotherapy a purveyor of thoracic trauma? Kinesitherapie. 2010;10(108):48-54 [Abstract provided by Science Direct]
  5. Heideken J, Svensson T, Blomqvist P, Haglund-Åkerlind Y, Janarv PM. Incidence and trends in femur shaft fractures in Swedish children between 1987 and 2005. Journal of Pediatric Orthopaedics. 2011;31(5):512-519 [Pubmed]
  6. Thompson NB, Kelly DM, Warner WC Jr, Rush JK, Moisan A, Hanna WR Jr, Beaty JH, Spence DD, Sawyer JR. Intraobserver and interobserver reliability and the role of fracture morphology in classifying femoral shaft fractures in young children. Journal of Pediatric Orthopedics. 2014;34(3):352-358 [Pubmed]

  7. Arnholz D, Hymel KP, Hay TC, Jenny C. Bilateral pediatric skull fractures: Accident or abuse? Journal of Trauma-Injury Infection & Critical Care. 1998;45:172-174 [Pubmed citation only]
  8. Hobbs CJ. Skull fracture and the diagnosis of abuse. Archives of Disease in Childhood. 1984;59(3):246-252 [Pubmed]
  9. Somers JM, Halliday KE, Chapman S. Humeral fracture in non-ambulant infants-a possible accidental mechanism. Pediatric Radiology. 2014;44(10):1219-1223 [Pubmed]

  10. Supakul N, Hicks RA, Caltoum CB, Karmazyn B. Distal humeral epiphyseal separation in young children: an often-missed fracture-radiographic signs and ultrasound confirmatory diagnosis. AJR. American Journal of Roentgenology. 2015;204(2):w192-198 [Pubmed]

  11. Royal College of Radiologists. Standards for Radiological Investigations of Suspected Non-accidental Injury. Joint document produced in collaboration with the Royal College of Paediatrics and Child Health. London: RCR [Most recent version available to download from RCR website]
  12. American College of Radiology. Practice Guideline for Skeletal Surveys in Children (PDF). [Most recent version available to download from ACR website]
  13. Helfer RE, Scheurer SL, Alexander R, Reed J,Slovis TL. Trauma to the bones of small infants from passive exercise: a factor in the etiology of child abuse. Journal of Pediatrics. 1984;104(1):47-50 [Pubmed]
  14. Grayev AM, Boal DKB, Wallach DM, Segal LS. Metaphyseal fractures mimicking abuse during treatment for clubfoot. Pediatric Radiology. 2001;31(8):559-563 [Pubmed]
  15. Altman DH, Smith RL. Unrecognised trauma in infants and children. Journal of Bone and Joint Surgery. 1960;42(3):407-413 [Pubmed citation only]
  16. Lysack JT, Soboleski D. Classic metaphyseal lesion following external cephalic version and cesarean section. Pediatric radiology. 2003;33(6):422-424 [Pubmed]
  17. Tsai A, McDonald AG, Rosenberg AE, Gupta R, Kleinman PK. High-resolution CT with histopathological correlates of the classic metaphyseal lesion of infant abuse. Pediatric Radiology. 2014;44(2):124-40 [Pubmed]

  18. Schulze C, Hoppe H, Schweitzer W, Schwendener N, Grabherr S, Jackowski C. Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy. Forensic Science International. 2013;233(1-3):90-8 [Pubmed]

  19. Love JC, Sanchez LA. Recognition of skeletal fractures in infants: an autopsy technique. Journal of Forensic Sciences. 2009;54(6):1443-1446 [Pubmed]
  20. Cappella A, Amadasi A, Gaudio D, Gibelli D, Borgonovo S, Di Giancamillo M, Cattaneo C. The application of cone-beam CT in the aging of bone calluses: a new perspective? International Journal of Legal Medicine. 2013;127(6):1139-44 [Pubmed]

  21. Doberentz E, Madea B, Müller AM. Coronal clefts in infants - rare differential diagnosis of traumatic injuries of vertebral bodies in battered children. Legal Medicine. 2014;16(6):333-336 [Pubmed]

  22. McAloon J, O'Neill C. Ossification centres, not rib fractures. Archives of Disease in Childhood. 2011;96(3):284 [Pubmed citation only]

  23. Harty MP, Kao SC. Intraosseous vascular access defect: fracture mimic in the skeletal survey for child abuse. Pediatric Radiology. 2002;32(3):188-190 [Pubmed]
  24. Quigley AJ, Stafrace S. Skeletal survey normal variants, artefacts and commonly misinterpreted findings not to be confused with non-accidental injury. Pediatric Radiology. 2014;44(1):82-93; quiz 79-81 [Pubmed]

  25. Sawyer JR, Kapoor M, Gonzales MH, Warner WC, Jr, Canale ST, Beaty JH. Heterotopic ossification of the hip after non-accidental injury in a child: case report. Journal of Pediatric Orthopaedics. 2009;29(8):865-867 [Pubmed]
  26. Kleinman PK, Sarwar ZU, Newton AW, Perez-Rossello JM, Rebello G, Herliczek TW. Metaphyseal fragmentation with physiologic bowing: a finding not to be confused with the classic metaphyseal lesion. American Journal of Roentgenology. 2009;192(5):1266-1268 [Pubmed]
  27. Choudhary AK, Jha B, Boal DK, Dias M. Occipital sutures and its variations: the value of 3D-CT and how to differentiate it from fractures using 3D-CT? Surgical and Radiologic Anatomy. 2010;32(9):807-816 [Pubmed]
  28. Saint-Martin P, Rerolle C, Alison D, Lefrancq T. Unossified membranous strip of the parietal bone: A differential diagnosis of non-accidental head trauma in children-a case report. Revue de Medecine Legale. 2012;3(1):45-47 [Abstract available from Science Direct]

  29. Slovis TL, Berdon WE, Haller JO, Baker DH, Rosen L. Pancreatitis and the battered child syndrome. Report of 2 cases with skeletal involvement. American Journal of Roentgenology, Radium Therapy & Nuclear Medicine. 1975;125(2):456-461 [Pubmed]
  30. Carter DR, Spengler DM. Mechanical properties and composition of cortical bone. Clinical Orthopaedics and Related Research. 1978;135:192-217 [Pubmed citation only]
  31. Oehmichen M, Meißner C, Schmidt V, Pedal I, König HG. Pontine axonal injury after brain trauma and nontraumatic hypoxic-ischemic brain damage. International Journal of Legal Medicine. 1999;112(4):261-267 [Pubmed]
  32. Pierce MC, Bertocci GE, Berger R, Vogeley E. Injury biomechanics for aiding in the diagnosis of abusive head trauma. Neurosurgery Clinics of North America. 2002;13(2):155-168 [Pubmed]
  33. Pierce MC, Bertocci G. Injury biomechanics and child abuse. Annual Review of Biomedical Engineering. 2008;10:85-106 [Pubmed]
  34. Worn MJ, Jones MD. Rib fractures in infancy: establishing the mechanisms of cause from the injuries - a literature review. Medicine, Science and the Law. 2007;47(3):200-212 [Pubmed]
  35. Docherty E, Hassan A, Burke D. Things that go bump ... bump ... bump: an analysis of injuries from falling down stairs in children based at Sheffield Children's Hospital. Emergency Medicine Journal. 2010;27(3):207-208 [Pubmed]
  36. Mooney JF 3rd, Cramer KE. Lower extremity compartment syndrome in infants associated with child abuse: a report of two cases. Journal of Orthopaedic Trauma. 2004;18(5):320-322 [Pubmed]
  37. Ravichandiran N, Schuh S, Bejuk M, Al-Harthy N, Shouldice M, Au H, Boutis K. Delayed identification of pediatric abuse-related fractures. Pediatrics. 2010;125(1):60-66 [Pubmed]
  38. Tenenbaum S, Thein R, Herman A, Cechik O, Shazar N, Zur S, Ganel A. Pediatric nonaccidental injury: Are orthopedic surgeons vigilant enough? Journal of Pediatric Orthopaedics. 2013;33(2):145-151.[Pubmed]

  39. Farrell C, Rubin DM, Downes K, Dormans J, Christian CW. Symptoms and time to medical care in children with accidental extremity fractures. Pediatrics. 2012;129(1):e128-e133 [Pubmed]
  40. Greeley CS, Donaruma-Kwoh M, Vettimattam M, Lobo C, Williard C, Mazur L. Fractures at diagnosis in infants and children with osteogenesis imperfecta. Journal of Pediatric Orthopedics. 2013;33(1):32-6 [Pubmed]

  41. Snedecor ST, Wilson HB. Some obstetrical injuries to the long bones. Journal of Bone and Joint Surgery. 1949;31A(2):378-384 [Pubmed citation only]
  42. Rajegowda BK, Chintalapalli P, Peralta D, Hernandez W. Unexpected detection of a newborn with multiple rib and clavicular fractures: birth injury? Neonatal Intensive Care. 2007;20(1):19-20 [Citation only - provided by British Library]
  43. van Rijn RR, Bilo RA and Robben SG. Birth-related mid-posterior rib fractures in neonates: a report of three cases (and a possible fourth case) and a review of the literature. Pediatric Radiology. 2009;39(1):30-34 [Pubmed]
  44. Barry PW, Hocking MD. Infant rib fracture - birth trauma or non-accidental injury. Archives of Disease in Childhood. 1993; 68:250 [Full article from Archives of Disease in Childhood]
  45. Hartmann RW. Radiological case of the month. Rib fractures produced by birth trauma. Archives of Pediatrics & Adolescent Medicine. 1997;151(9):947-948 [Pubmed citation only]
  46. O'Connell A, Donoghue VB. Can classic metaphyseal lesions follow uncomplicated caesarean section? Pediatric Radiology. 2007;37(5):488-491 [Pubmed]
  47. Morris S, Cassidy N, Stephens M, McCormack D, McManus F. Birth-associated femoral fractures: incidence and outcome. Journal of Pediatric Orthopedics. 2002;22(1):27-30 [Pubmed]
  48. Harwood-Nash DC, Hendrick EB, Hudson AR. The significance of skull fractures in children: A study of 1,187 patients. Pediatric Radiology. 1971;101,151-156 [Pubmed citation only]
  49. Lucas-Herald A, Butler S, Mactier H, McDevitt H, Young D, Faisal A. Prevalence and characteristics of rib fractures in ex-preterm infants. Pediatrics. 2012;130(6):1116-1119 [Pubmed]

  50. Bullock DP, Koval KJ, Moen KY, Carney BT, Spratt KF. Hospitalized cases of child abuse in America: who, what, when, and where. Journal of Pediatric Orthopedics. 2009;29(3):231-237 [Pubmed]
  51. Hansoti B, Beattie TF. Limb fractures and nonaccidental injury in children less than 24 months of age. European Journal of Emergency Medicine. 2008;15(2):63-66 [Pubmed]
  52. Leventhal JM, Larson IA, Abdoo D, Singaracharlu S, Takizawa C, Miller C, Goodman TR, Schwartz D, Grasso S, Ellingson K. Are abusive fractures in young children becoming less common? Changes over 24 years. Child Abuse and Neglect. 2007;31(3):311-322 [Pubmed]


^ back to top