Inflicted fractures and other non-accidental musculoskeletal injury

Overview & Definition

A six-month-old who cannot yet crawl is brought with a swollen, irritable thigh. The story is a "roll off the sofa," yet the femur is spiralled and the infant has not moved independently once in her life. That is the consultation this topic is about: an injury whose mechanism does not fit the child, the story, or the developmental stage, and that therefore demands you convert from treating a fracture to investigating possible inflicted injury. ^{[1] [2]}

Inflicted or non-accidental musculoskeletal injury covers skeletal injury caused by inflicted force or by failure to protect — recognised through fracture patterns whose specificity for abuse runs from high to low. Kemp's systematic review remains the anchor: rib fractures (especially posterior), the classic metaphyseal lesion, and fractures of the scapula, sternum and spinous process carry the highest specificity for abuse, while clavicular and linear skull fractures sit near the common, low-specificity end. ^{[1] [16]}

Two framing principles govern everything that follows, and the candidate who omits either mis-states the topic. First, no fracture is pathognomonic — a high-specificity pattern raises concern, it does not by itself prove abuse, and the diagnosis rests on a balanced assessment of the history, mechanism, pattern, developmental stage and the family context. Second, specificity outranks sensitivity: the question for an examiner is never "is this fracture seen in abuse?" but "how strongly does this fracture, in this child, point away from an accidental explanation?" ^{[1] [3]}

This leaf owns the fracture patterns, biomechanics, skeletal-survey protocol and the multi-domain assessment. Cross-link the safeguarding-recognition leaf for the forensic and mandatory-reporting pathway, the abusive-head-trauma leaf for the intracranial and retinal injury that travels with skeletal injury, and the bone-fragility leaf for the osteogenesis imperfecta differential — do not clone those chapters here. ^{[4] [8]}

References16ShowHide

1. [1]Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S Patterns of skeletal fractures in child abuse: systematic review. BMJ, 2008.PMID 18832412
2. [2]Kocher MS, Kasser JR Orthopaedic aspects of child abuse. J Am Acad Orthop Surg, 2000.PMID 10666649
3. [3]Lonergan GJ, Baker AM, Morey MK, Boos SC From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics, 2003.PMID 12853657
4. [4]Section on Radiology, American Academy of Pediatrics Diagnostic imaging of child abuse. Pediatrics, 2009.PMID 19403511
5. [5]Pandya NK, Baldwin K, Wolfgruber H, Christian CW, Drummond DS, Hosalkar HS Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. J Pediatr Orthop, 2009.PMID 19700994
6. [6]Maguire S, Mann M, John N, Ellaway B, Sibert JR, Kemp AM Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review. Child Abuse Negl, 2006.PMID 16857258
7. [7]Tsai A, Coats B, Kleinman PK Biomechanics of the classic metaphyseal lesion: finite element analysis. Pediatr Radiol, 2017.PMID 28721473
8. [8]Perez-Rossello JM, McDonald AG, Rosenberg AE, Tsai A, Kleinman PK Absence of rickets in infants with fatal abusive head trauma and classic metaphyseal lesions. Radiology, 2015.PMID 25688889
9. [9]Thackeray JD, Wannemacher J, Adler BH, Lindberg DM The classic metaphyseal lesion and traumatic injury. Pediatr Radiol, 2016.PMID 26902299
10. [10]Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C Prevalence of abuse among young children with femur fractures: a systematic review. BMC Pediatr, 2014.PMID 24989500
11. [11]Lindberg DM, Berger RP, Reynolds MS, et al. Yield of skeletal survey by age in children referred to abuse specialists. J Pediatr, 2014.PMID 24630357
12. [12]Karmazyn B, Lewis ME, Jennings SG, Hibbard RA, Hicks RA The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? AJR Am J Roentgenol, 2011.PMID 21700979
13. [13]Wootton-Gorges SL, Soares BP, Alazraki AL, et al. ACR Appropriateness Criteria Suspected Physical Abuse-Child. J Am Coll Radiol, 2017.PMID 28473090
14. [14]Harper NS, Lewis T, Eddleman S, et al. Follow-up skeletal survey use by child abuse pediatricians. Child Abuse Negl, 2016.PMID 26342432
15. [15]Hansen KK, Keeshin BR, Flaherty E, et al. Sensitivity of the limited view follow-up skeletal survey. Pediatrics, 2014.PMID 25070311
16. [16]Maguire S Which injuries may indicate child abuse? Arch Dis Child Educ Pract Ed, 2010.PMID 20926622