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Fractures in physical abuse

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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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


  • 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


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