Fractures are the second most common abusive injury, behind only cutaneous injuries. Like other abusive injuries, fractures can be very difficult to identify clinically, and for this reason, a radiographic skeletal survey is recommended for most children < 24 months old (and for many up to 36 months) when abuse is being considered. To be useful, a skeletal survey needs to be conducted according to published guidelines, which require high-resolution technique and approximately 20 different dedicated films. When performed properly, a skeletal survey uses only 0.2 mSv of radiation, so transfer to an experienced pediatric center is almost always to be preferred over performing an informal survey or a single-view “babygram” that does not conform to guidelines.
More than any other injury, radiographic signs of healing can be used to estimate the age of fractures, with periosteal reaction and callus formation commonly occurring between 7 and 14 days after injury. While no fracture is pathognomonic for abuse, rib fractures, classic metaphyseal fractures, and multiple fractures of different ages are highly concerning, and should prompt a thorough abuse evaluation. Fractures of the sternum, scapula, spine, pelvis, hands, or feet are uncommon in young children and should prompt a concern for abuse when there is not a clear history of significant trauma.
Classic Metaphyseal Lesions (CMLs). Note multiple, bilateral CMLs in both distal femurs and both proximal and distal tibias, with the proximal humerus, these are the most common locations for CMLs. (Photo contributor: Angie L. Miller, MD.)
Classic Metaphyseal Lesions (CMLs). This child had bilateral CMLs of the distal tibias, with bucket-handle morphology. (Photo contributor: Angie L. Miller, MD.)
Classic Metaphyseal Lesion (CML). Skeletal survey demonstrates a bucket-handle morphology of this metaphyseal fracture of the proximal humerus. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)
Management and Disposition
As with any abusive injury, abusive fractures should prompt testing for other abusive injuries or medical disease, should be reported to child protective services, and require the identification of a safe environment prior to discharge. Fractures that are most concerning for abuse (rib fractures and classic metaphyseal fractures) do not usually require splinting or casting and are commonly self-limited. Because healing can identify fractures that are missed initially, a follow-up skeletal survey is commonly obtained at least 10 to 14 days after the initial survey when the initial survey is indeterminate or when there is moderate or high concern for abuse. Films of the skull, spine, and pelvis are usually omitted from these follow-up surveys, ...