Fractures Linked to Child Abuse: AAP Diagnostic Guidelines

Laird Harrison

January 27, 2014

Recent advances in understanding the causes of fractures make it easier for clinicians to identify victims of child abuse, according to a report by the American Academy of Pediatrics.

The report, published online January 27 in Pediatrics, updates the academy's 2006 guidelines for differential diagnosis of fractures caused by child abuse.

Abuse causes between 12% and 20% of all fractures in infants and children, write Emalee G. Flaherty, MD, a pediatrics professor at Northwestern University in Chicago, Illinois, and colleagues. However, in children younger than 3 years, physicians misdiagnose as many as 20% of fractures caused by abuse, the authors found. The percentage of fractures caused by abuse declines after children learn to walk.

Any bone may be fractured by abuse, but rib fractures in infants and toddlers are particularly likely to be the result of abuse, the researchers note. Although cardiopulmonary resuscitation has been proposed as a mechanism for rib fractures, these fractures rarely occur when it is performed correctly, they explain.

Classic metaphyseal lesions, a type of long bone fracture, are also often caused by abuse, Dr. Flaherty and colleagues report. The femur, humerus, and tibia are the most common long bones fractured in child abuse.

In the nonambulatory child, femoral fractures are more likely to be caused by child abuse, whereas these fractures in ambulatory children are rarely inflicted by abuse, the authors note. Children often fall, and the falls can cause fractures, but these fractures rarely result in other significant injuries, such as to the nervous system.

In addition, multiple fractures, fractures in different stages of healing, and complex skull fractures have a moderate probability of being caused by abuse.

Among their recommendations for physicians evaluating children:

  • understand the mechanisms of fractures to determine whether a fracture is caused by abuse or something else;

  • take a complete medical history, family history, and social history to determine how an injury occurred, as bone disease and other preexisting medical conditions can make a child's bones more fragile;

  • take a careful history of any injury and then determine whether the mechanism described and the severity and timing are consistent with the injury; and

  • evaluate siblings of children who have been physically abused.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online January 27, 2014.


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