Child Protection Evidence - Fractures

Child Protection Evidence is a resource available for clinicians across the UK and internationally to inform clinical practice, child protection procedures and professional and expert opinion in the legal system. This review evaluates the literature on abusive and non-abusive fractures.

Review updated: February 2015

About the review

The following is a summary of the systematic review findings up to the date of our most recent literature search. 

The systematic review evaluates the scientific literature on fractures published up until February 2015.

It aims to answer the following clinical questions: 

  • Which fractures are indicative of abuse?
  • What is the evidence for radiological dating of fractures in children?
  • What radiological investigations should be performed to identify fractures in suspected child abuse?
  • Does cardiopulmonary resuscitation cause rib fractures in children?

Fractures are a common manifestation of abuse and are essential to identify if present. This review evaluates the scientific literature on abusive and non-abusive fractures and examines their features based both on their location and age-group.  

The implications for practice and research, and other useful references are included in the review.

Key findings

  • Fractures in children less than 18 months of age should be assessed for possible child abuse.
  • Multiple fractures are more suspicious of abuse.
  • The dating of fractures is an inexact science, the radiological features of bone healing represent a continuum, with considerable overlap.
  • Radiological estimates of time of injury are in terms of weeks rather than days.  It is vital that all investigating agencies are aware of these broad time frames.
  • Either skeletal survey (SS) or radionuclide imaging (RNI) alone will miss occult fractures; optimal assessment should include both investigations.
  • If RNI is the first line of investigation, an additional skull X-ray must be performed and coned views of the metaphyses should be considered.
  • Recent studies suggest that up to 12% of household contacts aged less than two may have a positive SS with twins being a particularly high risk.

Systematic review on Fractures (PDF, 508 KB, 66 Pages)


Disclaimer: This 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.

Original reviews and content © Cardiff University, funded by NSPCC
Published by RCPCH July 2017

While the format of each review has been revised to fit the style of the College and amalgamated into a comprehensive document, the content remains unchanged until reviewed and new evidence is identified and added to the evidence-base. Updated content will be indicated on individual review pages.