Fracture where child maltreatment should be considered

As with bruises, it is possible for a child to injure him or herself, but these injuries generally take a certain form, and are usually age appropriate. Thus, a child who cannot walk is unlikely to be able to fracture a leg. The other mode of presentation is as an undiagnosed event - ie a child who is in pain for some reason apparently unclear to the parent.

Possible presenting features include:

• pain in a limb, with the infant or child reluctant to move that limb
• a number of fractures, particularly at different ages - ie in different stages of healing
• spiral fractures from twisting
• rib fractures from crushing; they tend to be posterior
• epiphyseal fractures from pulling

NICE have produced guidance as to fractures where child maltreatment should be considered:

• suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones (for example, osteogenesis imperfecta, osteopenia of prematurity) or if the explanation is absent or unsuitable. Presentations include:
  • fractures of different ages
  • X-ray evidence of occult fractures (fractures identified on X-rays that were not clinically evident). For example, rib fractures in infants

Notes:

• for the purposes of this guideline, to suspect child maltreatment means a serious level of concern about the possibility of child maltreatment but is not proof of it
• a bucket-handle fracture describes the radiological appearance of a type of metaphyseal fracture associated with non accidental injury

Reference:

• 1. NICE (July 2009). When to suspect child maltreatment.