Fractures: systematic review

Child Protection Evidence is a resource for clinicians across the UK and internationally to inform clinical practice, child protection procedures and professional and expert opinion in the legal system.


Fractures have been recorded in as many as 55% of young children who have been physically abused, 18% of whom have multiple fractures. Fractures in physical child abuse denote severe assault and young children are at greatest risk of abusive fractures. Many abusive injuries can be clinically occult and investigative strategies are designed to maximise their early detection, potentially preventing escalation of physical abuse to more serious injury.

This systematic review has been updated and now evaluates the scientific literature published up until March 2020 that compares abusive and non-abusive fractures in children. There are increasing numbers of high quality studies being published in this field, which continue to address the value of skeletal surveys in different populations and fracture patterns associated with abuse.

In the 2020 systematic review update, seven new studies have been included, most adding to a growing body of literature about classic metaphyseal lesions (CMLs). This includes two studies reviewing the distinguishing features of abusive CMLs, a study assessing subperiosteal new bone formation with distal tibial CMLs, and another study on ultrasound findings in CMLs. Another reviewing the signs of acute and healing distal tibial CMLs. We have also included a study on the yield of additional fractures identified with a skeletal survey in young children with a femoral fracture, and a further study looked at avoiding skull radiographs in children with suspected inflicted injury who also underwent a head CT scan.

The review aims to answer four clinical questions:

    1. Which fractures are indicative of abuse?
    2. What is the evidence for radiological dating of fractures in children?
    3. What radiological investigations should be performed to identify fractures in suspected child abuse?
    4. Does cardiopulmonary resuscitation cause rib fractures in children?

Key findings

    • Abusive fractures are more common in children less than 18 months of age than in those older than 18 months
    • Abused children were more likely to have multiple fractures than non-abused children
    • Rib fractures in the absence of major trauma, birth injury or underlying bone disease have a high predictive value for abuse
    • Multiple rib fractures are more commonly abusive than non-abusive
    • Abusive femoral fractures are more likely to arise in children who are not yet walking
    • Mid-shaft fractures are the most common femoral fractures in abuse and non-abuse (analysed for all age groups)
    • Supra condylar humeral fractures in children are associated with accidental injury whilst the most common abusive humeral fractures in children aged less than five years are spiral or oblique
    • Humeral fractures in those aged less than 18 months have a stronger association with abuse than humeral fractures in older children
    • Linear fractures are the most common abusive and non-abusive skull fractures
    • Metaphyseal fractures are more commonly described in physical child abuse than in non-abuse
    • Metaphyseal fractures have been frequently described in fatal abuse
    • Most children with classic metaphyseal lesions (CML) have other associated injuries which are often multiple
    • Pelvic, hand, feet and sternal fractures occur in physical abuse and appropriate radiology is required for their detection
    • The dating of fractures is an inexact science, the radiological features of bone healing represent a continuum, with considerable overlap in timescale
    • The accuracy of radiological estimates of the time of injury are in terms of weeks rather than days
    • Radiological investigations of suspected physical abuse include initial and follow up skeletal surveys with specific views to maximise detection of occult injuries particularly in young children
    • Studies suggest that up to 12% of contacts under two years of age, of children who have been abused with serious injuries, may have a positive skeletal survey, with twins being a particularly high risk.
Disclaimer: This is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.

Original reviews and content © Cardiff University, funded by NSPCC

Published by RCPCH September 2020

While the format of each review has been revised to fit the style of the College and amalgamated into a comprehensive document, the content remains unchanged until reviewed and new evidence is identified and added to the evidence-base. Updated content will be indicated on individual review pages.

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