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 systematic review evaluates the literature on abusive and non-abusive fractures.

About the review

This systematic review evaluates the scientific literature on fractures published up until March 2020.

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.

Key findings

  • Abusive fractures are more common in children less than 18 months of age than in those older than 18 months.
  • Abused children were more likely to have multiple fractures than non abused children.
  • Rib fractures in the absence of major trauma, birth injury or underlying bone disease have a high predictive value for abuse.
  • Multiple rib fractures are more commonly abusive than non-abusive.
  • Abusive femoral fractures are more likely to arise in children who are not yet walking.
  • Mid-shaft fractures are the most common femoral fractures in abuse and non-abuse (analysed for all age groups).
  • Supra condylar humeral fractures in children is associated with accidental injury whilst the most common abusive humeral fractures in children aged less than five years are spiral or oblique.
  • Humeral fractures in those aged less than 18 months have a stronger association with abuse than humeral fractures in older children.
  • Linear fractures are the most common abusive and non-abusive skull fractures.
  • Metaphyseal fractures are more commonly described in physical child abuse than in non-abuse.
  • Metaphyseal fractures have been frequently described in fatal abuse.
  • Most children with classic metaphyseal lesions (CML) have other associated injuries which are often multiple.
  • Pelvic, hand, feet and sternal fractures occur in physical abuse and appropriate radiology is required for their detection.
  • The dating of fractures is an inexact science, the radiological features of bone healing represent a continuum, with considerable overlap in timescale.
  • The accuracy of radiological estimates of the time of injury are in terms of weeks rather than days.
  • Radiological investigations of suspected physical abuse include initial and follow up skeletal surveys with specific views to maximise detection of occult injuries particularly in young children.
  • Studies suggest that up to 12% of contacts under two years of age, of children who have been abused with serious injuries may have a positive skeletal survey with twins being a particularly high risk.

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
Updates and new material by RCPCH September 2020

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.