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.
- 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
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.