Know the common patterns or features of fractures associated with inflicted injury. Child abuse is a common cause of skeletal fractures in young children, especially in those younger than 2 years. Children who are not independent walkers rarely have accidental fractures of their long bones. When such fractures do occur in this age group, there is usually a clear-cut history of a fall or other plausible injury. Any fracture in a nonambulatory child should raise the clinician’s index of suspicion for abuse.

Several factors in the clinical history should alert the clinician to the possibility of nonaccidental trauma. Unexplained or unwitnessed injuries leading to fractures, especially in small children, are suspect for abuse. When the reported mechanism of injury is inconsistent with the child’s developmental stage or with the injuries noted on exam or x-ray, the likelihood of inflicted injury is significantly higher. Also of concern is a changing or implausible history, a history that suggests the child was injured by a sibling or another caregiver, or contradictory histories obtained from separate caregivers.

Many nonaccidental fractures are solitary. However, some children will have a history of repeated injuries, with visits to a variety of health care providers in search of treatment. Multiple fractures, especially those in various stages of healing, or fractures associated with other injuries, such as burns or bruises, should make the examiner suspicious of child abuse.

The classic metaphyseal lesion occurs as a result of a shearing injury and represents a series of microfractures across the metaphysis. A classic metaphyseal lesion, also called the corner or bucket handle fracture based on its radiographic appearance, is pathognomonic for inflicted injury. Furthermore, in the absence of a history of trauma, rib fractures in young children are highly suspicious for inflicted injury. These fractures are often sustained along the posterior and lateral aspects of the ribs, and result from the compression forces exerted while being tightly held around the thorax. Finally, scapular fractures or fractures of different ages are highly correlated with inflicted injury.