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A cast is seen on an infant's leg.

Could fracture be due to abuse? AAP clinical report outlines how to approach cases of suspected maltreatment

January 21, 2025

A 4-month-old is brought to the emergency department (ED) with leg swelling and decreased movement since waking this morning. A large, firm, tender area is noted in the midshaft of the left thigh, and the child becomes very upset every time the leg is moved. An X-ray shows a midshaft transverse femur fracture. The family reports no history of trauma. Should the provider be concerned about physical abuse, and how should the child’s care be approached?

Child maltreatment is reported in 42 per 1,000 children annually, making it far more common than many illnesses and conditions seen in the ED. Therefore, maltreatment should be on the differential diagnosis list for many children who present to the ED with injuries as well as those seen in the office setting.

Pediatricians, however, often note that they do not feel equipped to diagnose or manage cases of suspected maltreatment.

The updated AAP clinical report Evaluating Young Children With Fractures for Child Abuse outlines when to be concerned that a fracture could be the result of abuse and how to approach those cases.

The report, from the Council on Child Abuse and Neglect, Section on Orthopaedics, Section on Radiology, Section on Endocrinology and the Society for Pediatric Radiology, is available at https://doi.org/10.1542/peds.2024-070074 and will be published in the February issue of Pediatrics.  

When to consider child abuse

Fractures are common unintentional injuries in childhood. Children fall while running, jump off playground equipment, crash while riding bicycles and do other risky things that cause injury.

In specific circumstances, however, providers should have a greater concern for abuse. For instance, infants and other nonambulatory children rarely generate enough force to break a bone. It is reasonable to take a second look at every infant with a fracture to ensure an abusive injury is not missed.

In addition, the history should match the injury. For example, it is conceivable that a 5-year-old can fall off the monkey bars and sustain a supracondylar humerus fracture. On the other hand, it does not make sense for a 4-week-old infant to present with a midshaft femur fracture without a history of injury.

Some types of fractures are more specific for abuse than others. Rib fractures and metaphyseal fractures (chip or bucket handle fractures) rarely are the result of an accident. One common misconception is that spiral fractures are specific for abuse; transverse fractures actually are seen more commonly in abuse.

What to do if abuse is suspected

The initial history, physical and imaging can help determine how likely or how concerning the injury is for abuse. In cases where abuse is more likely, it is prudent to evaluate for other injuries and rule out possible medical causes such as osteogenesis imperfecta and metabolic bone disease.

A skeletal survey often is the first study ordered. This detailed study entails imaging all areas of the skeleton to look for prior injury or indications of skeletal anomalies. It should incorporate at least 22 separate images and usually is done at a center experienced in caring for children.

Skeletal surveys are helpful up until about 2 years of age and are not indicated in children older than age 5. In addition, they can wait until a child is stable.

If a provider has questions about how to conduct an evaluation or is unsure how to proceed, a child abuse pediatrician can provide assistance. Child abuse pediatricians are trained in abuse mimics and how to evaluate suspected abuse cases.

Contrary to some recent media portrayals, many child abuse pediatricians report that they do not diagnose abuse in up to 40% of the cases they see and even overturn a diagnosis of abuse made by other providers.

When there is a reasonable concern that a child’s injuries are the result of abuse, medical professionals are required to inform law enforcement and child protective services. Every state has a different legal process and reporting requirements. Therefore, it is important for pediatricians to be aware of their state’s requirements.

Key points and recommendations

  • Determining if a fracture is the result of abuse involves understanding whether the injury is consistent with the history of how it occurred.
  • Medical, family and social history can uncover conditions that affect bone strength, inherited bone diseases and risk factors for abuse.
  • Certain fractures such as rib and metaphyseal fractures are more specific for abuse and usually warrant an evaluation for abuse.
  • Most states mandate reporting when there is reasonable concern that the child has been abused.
  • Child abuse pediatricians have unique skills and training to assist in determining if an injury is the result of abuse.
  • Providers should be aware of concerns regarding racial and ethnic bias in the diagnosis of child abuse and work to reduce bias.

Dr. Haney is a lead author of the report and a former member of the AAP Council on Child Abuse and Neglect Executive Committee.

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