Evaluating Young Children With Fractures for Child Abuse: Report From the AAP

Unintentional fractures and fractures due to abuse are common in infants and children. Approximately one-fourth of fractures in infants younger than 12 months and about 80% of fractures in children younger than 18 months are from abuse. The American Academy of Pediatrics (AAP) published a clinical report of best practices based on expert opinion to guide physicians in differentiating child abuse from other causes.

Although no fracture type is pathognomonic for abuse, some demonstrate increased risk.

Classic Metaphyseal Lesions. Classic metaphyseal lesions (planar fractures through the metaphyseal primary spongiosa) are highly specific for infant abuse caused by vigorous extremity pulling or twisting or bending joint strain from inversion or eversion.

High-Energy Fractures Without Mechanism. Without high-energy trauma, sternal, scapular, spinal, or pelvic fractures are suggestive of abuse. Rib fractures unrelated to motor vehicle collisions or metabolic bone disease have up to a 95% positive predictive value for abuse in children younger than 3 years.

Long Bone Fractures in Nonambulatory Children. The femur, humerus, or tibia is most likely to be injured by abuse. Up to 54% of humerus fractures in children younger than 3 years are from abuse. Risk is higher in younger children, with nearly 75% of lower extremity fractures in children younger than 18 months attributed to abuse.

Multiple Fractures. One-half of children diagnosed with abuse have more than one fracture. In one study, having three or more fractures increases the risk for abuse fourfold. Fractures in different stages of healing increase the likelihood of abuse.

Complex Skull Fractures. Bilateral acute symmetric fractures in infants suggest shaking. Fractures that are stellate, depressed, multiple, or across suture lines are more concerning for abuse.

Displaced Physeal Fractures. A skeletal survey is recommended for displaced physeal fractures in children younger than 24 months. Displaced physeal fractures, most often Salter-Harris 1 fracture of the humerus, are 13 times more likely to be from abuse compared with displaced supracondylar fractures.

Clavicular Fractures. Clavicular fractures are common in birth trauma. Short falls can cause midshaft fractures, but distal and proximal clavicular fractures are uncommon in children younger than 3 years and should prompt evaluation for possible abuse.