Bone fractures

When should fractures raise concerns of child abuse?

By Will Boggs MD

NEW YORK (Reuters Health) - Specific features of fractures in children raise the suspicion of physical abuse, according to a new guidance from the American Academy of Pediatrics (AAP).

"Any childhood injury, including fractures, can be caused by child abuse, regardless of the child's race, ethnicity or socio-economic circumstances," Dr. Emalee G. Flaherty from Lurie Children's Hospital of Chicago told Reuters Health by email. "Physicians should always consider the possibility that a fracture could have been caused by child abuse."

"A complete history of the event, a thorough physical examination and evaluation, an understanding of the mechanism of certain fractures, and the presence of other injuries should help physicians and other clinicians to recognize this hidden danger," Dr. Flaherty said.

Dr. Flaherty and fellow members of AAP's Committee on Child Abuse and Neglect reviewed recent advances in the understanding of fracture mechanisms and medical diseases that predispose to fractures in infants and children in hopes of aiding physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

Fractures most specific for child abuse include metaphyseal lesions of long bones, rib fractures (especially posteromedial), scapular fractures, spinous process fractures, and sternal fractures, according to their publication online January 27th in Pediatrics.

Other features that should raise the specter of child abuse include:

  • no history of injury
  • implausible history of injury
  • inconsistent or changing histories provided by caregiver
  • fracture in a nonambulatory child
  • presence of multiple fractures
  • fractures of different ages
  • other injuries suspicious of child abuse
  • delay in seeking care for an injury.

On the other hand, various other conditions can increase the risk of fractures in children, among them osteogenesis imperfecta, preterm birth, vitamin D deficiency rickets, osteomyelitis, demineralization from disuse, copper deficiency, Menkes disease, and other diseases.

But Dr. Flaherty said these are "very rarely the cause of fractures in an otherwise healthy infant or child."

Children under two years (and some children between two and five years) with fractures suspicious for child abuse should undergo a radiographic skeletal survey, for which the American College of Radiology has developed specific practice guidelines.

Head imaging should also be considered in children younger than one year with a fracture suspicious for abuse because brain injuries are often occult.

Siblings and other young household members of physically abused children should also be evaluated for maltreatment, according to the guidance.

The guidance also reminds physicians that all US states, commonwealths, and territories have mandatory reporting requirements for physicians and other health care providers when they suspect child abuse.

Coauthor Dr. Michael A. Levine from Children's Hospital of Philadelphia told Reuters Health by email, "Non-accidental trauma can be the cause of injury, including and fractures, to any child, regardless of socio-economic circumstances. Consulting physicians and other clinicians should learn to recognize the patterns of injury that can serve as signals to this hidden danger."

"It is imperative to identify non-accidental trauma as a cause of fractures to prevent future injury to the child," Dr. Levine said.

Dr. Jeannette M. Perez-Rossello, pediatric radiologist from Harvard Medical School, Boston, Massachusetts also contributed to the guidance. She told Reuters Health, also by email, "Fractures are one of the strongest indicators that child abuse has occurred. Pediatric radiologists play a critical role in identifying the skeletal injuries that have high specificity for abuse like rib fractures and classic metaphyseal lesions."

"Our report will aid physicians in developing an evidence base (for) differential diagnosis and guide in the laboratory and imaging evaluation of a child with fractures and suspected abuse," Dr. Perez-Rossello concluded.


Pediatrics 2014;133:e477-e489.

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