Fractures are a common sign of abuse. It is impossible to tell from an x-ray alone whether or not a fracture is due to abuse. Fractures of the extremities are the most common skeletal injury in children who have been abused and approximately 80% of fractures due to abuse occur in children under 18 months old.¹ In non-mobile children, rib fractures, long bone fractures, and metaphyseal fractures have a high correlation with child abuse. An understanding of the motor development of young children can aid physicians in the identifying fractures due to abuse.

Case

Isaac is 8 months old. His parents say that he was walking and tripped on a toy. Since that time, he has been crying and won’t move his right leg. On x-ray, you note a right femur fracture.

In this case, an 8 month old may be pulling to stand, but should not yet be walking. This typically begins around 12 months of age. Most cases of femur fracture in children are due to falls from a height, and few are due to running or playing. A femur fracture from walking and slipping on a toy would be extremely unusual without an underlying condition. If abusive injury is suspected, a skeletal survey should be done at the time of presentation as long as the child is stable. It should also be repeated in 2-3 weeks to evaluate for healing fractures.

Red Flags for Fractures from Abuse:

• Children <1 year old with a fracture
• Femur, rib, and metaphyseal fractures in non-mobile children
• Fractures in various stages of healing
• Multiple fractures
• Unusual fractures: scapula, vertebrae, sternum

Additional Red Flags That Should Raise Concern for Abuse:

• No explanation or vague explanation for a serious injury
• Details of story continue to change
• Delay in seeking medical care

Author information

Emily Frank, MD

Pediatrics Resident
University of California San Francisco

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