What is the pathophysiology of physical child abuse-related fractures?

Updated: Apr 24, 2017
  • Author: Angelo P Giardino, MD, MPH, PhD; Chief Editor: Caroly Pataki, MD  more...
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While certain types of fractures (eg posterior rib, scapular, classic metaphyseal lesions) are more common in physical abuse than accidental injury, there is no fracture that is pathognomonic for child physical abuse. All fractures must be carefully evaluated and correlated with the child's medical history and with the history given by the caregivers. Fractures can be classified by location in the body (eg skull vs long bone) and then by location in the bone (eg diaphyseal vs metaphyseal, posterior vs anterior rib). Certain fracture types are only seen in developing, immature bone (eg, greenstick, classic metaphyseal lesions, Salter-Harris fractures).

Specifically in long bones, fractures are described based on location and type. Diaphyseal fractures are breaks in the mid shaft of the long bones. Transverse fractures typically occur if the force is applied perpendicular to the long axis of the bone. Spiral or oblique fractures occur if the force applied has a rotational component. Buckle or compression fractures occur commonly at the transition from diaphysis to metaphysis. Note the images below.

Buckle fracture of distal femur without healing (a Buckle fracture of distal femur without healing (acute).
Distal femur buckle fracture, 2-week follow-up fil Distal femur buckle fracture, 2-week follow-up film with sclerotic fracture line and periosteal new bone healing.

Metaphyseal fractures (also called corner fractures or bucket handle fractures) are microfractures through the immature part of the bone edge and often appear like chips or corner fractures on radiographs. The metaphysis is an area of rapid bone turnover in the growing infant and toddler. Metaphyseal fractures are specific to infants as they involve the immature physis; they are caused by shearing and tensile stress seen in rapid acceleration and deceleration forces to the extremity.

Skull bones may be fractured as a result of direct impact to the head with a solid surface or object. Skull fractures typically occur at the site of impact to the head, but owing to the oval shape of the head, a single point of impact may result in bilateral fractures remote from the site of impact. The skull bones differ from long bones in that they develop within a membrane and not from cartilage as do the long bones.

Rib fractures may be observed in physical abuse as well. Rib fractures occur as a result of direct blows to the chest and via anteroposterior compression. Most abusive rib fractures are posterior, adjacent to the vertebral body, with the rib levering over the transverse process of the vertebra.

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