What features of a musculoskeletal injury should prompt an examining physician to suspect child abuse?

It is an unfortunate reality that some children are victims of abuse by parents and other family members. Premature, unplanned, or handicapped children are at particular risk, as are stepchildren, but abuse is certainly not limited to these children alone. All states require certain professionals or institutions to report suspected child abuse (known as “mandatory reporting”). Needless to say, reporting child abuse requires recognizing child abuse. While this topic is broad with multiple psychosocial and judicial implications, here we focus on the role of the musculoskeletal provider in identifying possible abuse.


Clinical suspicion should be raised when the described mechanism of injury is vague, unwitnessed, or inconsistent with clinical findings. Injuries incongruous with the child’s developmental stage, such as a femur fracture or skull fracture before the child can walk, should prompt further investigation.

Soft Tissue Injury

If a child does not walk, bruising anywhere should raise suspicion of abuse. Toddlers, as the term suggests, are unsteady on their feet and do fall. Bruises are common but bruising over non-bony prominences may indicate abuse.


Skeletal fracture is the second most common manifestation of child abuse (roughly one-third to one-half of abused children will sustain fractures). While no fracture location or pattern is pathognomonic for child abuse, certain fracture locations and patterns correlate highly with inflicted trauma, some examples of which are listed below:

  • Multiple fractures in various stages of healing suggest ongoing, repetitive physical abuse.
  • Rib fractures have the highest specificity for abuse. Rib fractures can be inflicted by direct blows or squeezing. Consecutive ribs are often broken in a pattern corresponding to the abuser’s finger placement. Rib fractures can be difficult to detect on x-ray because they are frequently non-displaced and have overlapping structures (Figure 1). Therefore, these fractures may be better visualized on x-rays taken during the healing phase 10-14 days post event.
Figure 1: Arrows point to multiple posterior rib fractures secondary to child abuse (image from Wikipedia.org)
  • Long bone fractures (Figure 2) of the femur, humerus, and tibia are the most common fractures of child abuse, but these are also common with accidental trauma.Isolated long bone fractures in non-ambulatory children should raise suspicion for abuse, though this is by no means diagnostic of abuse.

Figure 2: AP (left) and Lateral (right) views of diaphyseal fracture of the right femur suspicious for non-accidental injury (adapted from Radiopaedia https://radiopaedia.org/cases/10321/studies/10840?lang=us)
  • Metaphyseal (“bucket handle” or “corner”) fractures (Figure 3) result from pulling or twisting an extremity suddenly and forcibly. Metaphyseal fracture is the fracture type most specific for non-accidental injury. This action causes separation of a peripheral metaphyseal bone fragment with attached subperiosteal bone collar, forming a mobile concave disk-shaped bone fragment.
Figure 3: “Bucket Handle” fracture of the left tibia (adapted from Radiopaedia https://radiopaedia.org/cases/13614/studies/13512?lang=us&referrer=%2Farticles%2Fmetaphyseal-corner-fracture-1%3Flang%3Dus%23image_list_item_894121)
  • Fractures of the sternum, scapula, and pelvis, when these fractures occur in the absence of plausible history (e.g. high-energy motor vehicle crash).
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