This 2014 AAP clinical report reviews how to evaluate children presenting with fractures for possible physical abuse. It synthesizes evidence on fracture-type specificity for abuse, the biomechanics underlying different fracture patterns, and the medical conditions — including OI, rickets, prematurity, and copper deficiency — that can mimic or coexist with abusive injury, guiding physicians through history, exam, labs, and imaging.
When you see a posteromedial rib fracture or classic metaphyseal lesion in an infant, treat it as abuse until proven otherwise — the PPV for abuse exceeds 95% for rib fractures in children under 3.
For any child under 2 with a suspicious fracture, obtain a full skeletal survey and plan a repeat survey at 2–3 weeks, because nearly two-thirds of occult fractures are missed on the initial study.
This 2014 AAP clinical report reviews how to evaluate children presenting with fractures for possible physical abuse. It synthesizes evidence on fracture-type specificity for abuse, the biomechanics underlying different fracture patterns, and the medical conditions — including OI, rickets, prematurity, and copper deficiency — that can mimic or coexist with abusive injury, guiding physicians through history, exam, labs, and imaging.
When you see a posteromedial rib fracture or classic metaphyseal lesion in an infant, treat it as abuse until proven otherwise — the PPV for abuse exceeds 95% for rib fractures in children under 3.
For any child under 2 with a suspicious fracture, obtain a full skeletal survey and plan a repeat survey at 2–3 weeks, because nearly two-thirds of occult fractures are missed on the initial study.