Non-Accidental Trauma Related Fractures

Aka: Non-Accidental Trauma Related Fractures, Fractures in Child Abuse

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II. Epidemiology

  1. Fractures due to abuse
    1. Age <12 months: 25%
    2. Age <18 months: 80%

III. Imaging: Fractures associated with Non-accidental Trauma

  1. Rib Fractures
    1. Rib Fractures overall are unusual in younger children (aside from major Trauma)
      1. Children have very compliant chest walls making Rib Fractures uncommon
      2. Probability of Non-accidental Trauma 71% for Rib Fractures without major Trauma
    2. Posterior or posteromedial Rib Fractures (without history of MVA or metabolic bone disease)
      1. Seen especially in infants related to compression from assailant's fingers wrapped around chest
      2. Highly predictive of Nonaccidental Trauma in age <3 years (PPV 95%)
  2. Metaphyseal chip Fracture (bucket handle Fracture)
    1. Distal long bone Fracture related to twisting mechanism of injury (or inversion or eversion)
  3. Spiral long bone Fracture (Humerus or femur) in age under 3 years old
  4. Skull Fractures that ar multiple, depressed or complicated
  5. Multiple Fractures in varying stages of healing
  6. Displaced physeal Fracture in age <24 months
  7. Distal extremity Fractures without a history of Trauma (e.g. Hand Fracture, Foot Fracture)
    1. Nimkin (1997) Radiology 203:233-6 [PubMed]
  8. Mechanism inconsistent with injury or developmental stage
    1. Long bone Fractures (femur, Humerus, tibia) in non-ambulatory children (e.g. a 4 month old is not ambulatory)
    2. High-Energy Fractures without mechanism
      1. Sternal Fracture
      2. Scapula Fracture
      3. Spinous process Fractures or Vertebral body Fractures
      4. Pelvic Fractures

IV. Imaging: Fractures with Lower Risk of Abuse (common with Trauma)

  1. Midshaft Clavicular Fractures
    1. However, distal and proximal Clavicular Fractures are uncommon
  2. Supracondylar Humerus Fracture
  3. Buckle Fracture of distal radius and ulna
  4. Femoral Fracture in ambulatory children
  5. Tibia Fracture
    1. Non-displaced spiral Fracture of distal tibia (Toddler's Fracture)
    2. Proximal tibia Fracture (common trampoline-related Fracture)
  6. Fractures associated with underlying medical conditions
    1. Osteogenesis Imperfecta
    2. Rickets (non-displaced Stress Fractures)

V. References

  1. Kleinman (1998) Diagnostic Imaging of Child Abuse, Mosby, St Louis, p. 9
  2. Majoewsky (2012) EM:RAP C3 2(7): 3
  3. Haney (2025) Pediatrics 155(2): e2024070074 [PubMed]
  4. Kemp (2008) BMJ 337:a1518 +PMID: 18832412 [PubMed]

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