Preverbal children presenting with acute fractures should bring about the suspicion of child abuse for the clinician. Thus, one must evaluate the child to determine if the true cause of the injury. The key in distinguishing between accidental and inflicted trauma involves a close look at the type of fracture, mechanism of injury, and history given by the parent.

The history must seem plausible for the child’s stage of development. For example, you see a 2-month-old infant who reportedly rolled off a bed presents with a femur fracture. This history raises suspicion of abuse because a 2-month-old child cannot typically roll at this stage of development. Other concerning clues in the history involve a relative lack of information, such as histories that seem vague or change over time. If the parents state a child fell down the stairs, they should be able to say how many stairs, where exactly it occurred, and at what time. These details should remain consistent throughout the interview.

Additionally, the history of the injury should be consistent with the type of fracture found on x-ray. Asking how the patient was initially standing, how he or she fell, and how they landed can give the clinician clues to the types of forces exerted on a bone and the likely fractures that should result. For example, spiral fractures tend result from torsional loading. A toddler who was running, twisted, and fell may have a nondisplaced oblique, spiral fracture of the distal tibia (toddler’s fracture). However, the same fracture in a nonambulatory 8-month-old infant would be highly suspicious of abuse.