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Orthopedic aspects of child abuse

Susan A Scherl, MD
Section Editors
William Phillips, MD
Daniel M Lindberg, MD
Deputy Editor
James F Wiley, II, MD, MPH


An overview of the orthopedic aspects of child abuse will be presented here.

The differential diagnosis of the orthopedic manifestations of child abuse, recognition of physical child abuse, and the diagnosis and management of physical child abuse is presented separately. (See "Differential diagnosis of the orthopedic manifestations of child abuse" and "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management".)


The epidemiology of the orthopedic aspects of child abuse will be discussed below. The epidemiology of child abuse, including risk factors in the perpetrators, victims, and environment, is discussed in detail separately. (See "Physical child abuse: Recognition", section on 'Epidemiology'.)

Soft-tissue injuries are the most common injuries identified in physical abuse and are present in as many as 92 percent of victims [1]. Fractures are the second most common injury and are present in as many as 55 percent of physically abused children, depending upon the type of abuse and the method of fracture detection [2-4].

Most inflicted fractures occur during infancy and early childhood [3], with as many as 85 percent occurring in children younger than three years, and 69 percent in children younger than one year [2,5,6]. The estimated annual incidence of fractures attributable to abuse is 36 cases per 100,000 children younger than 12 months, and 5 cases per 100,000 children between 12 and 35 months [7].

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Literature review current through: Nov 2017. | This topic last updated: Mar 06, 2017.
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  1. McMahon P, Grossman W, Gaffney M, Stanitski C. Soft-tissue injury as an indication of child abuse. J Bone Joint Surg Am 1995; 77:1179.
  2. King J, Diefendorf D, Apthorp J, et al. Analysis of 429 fractures in 189 battered children. J Pediatr Orthop 1988; 8:585.
  3. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000; 8:10.
  4. Albert, MJ, Drvaric, DM. Injuries resulting from pathologic forces: child abuse. In: Pediatric Fractures: A Practical Approach to Assessment and Treatment, MacEwen GD, Kasser JR, Heinrich SD (Eds), Williams and Wilkins, Baltimore 1993. p.388.
  5. Akbarnia B, Torg JS, Kirkpatrick J, Sussman S. Manifestations of the battered-child syndrome. J Bone Joint Surg Am 1974; 56:1159.
  6. Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child 1993; 147:87.
  7. Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics 2008; 122:599.
  8. Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics 2010; 125:60.
  9. Green M, Haggerty RJ. Physically abused children. In: Ambulatory Pediatrics, WB Saunders, Philadelphia 1968. p.285.
  10. Kogutt MS, Swischuk LE, Fagan CJ. Patterns of injury and significance of uncommon fractures in the battered child syndrome. Am J Roentgenol Radium Ther Nucl Med 1974; 121:143.
  11. Saade DN, Simon HK, Greenwald M. Missed opportunities for recognition in the ED. Acad Emerg Med 2002; 9:524.
  12. Smith SM, Hanson R. 134 battered children: a medical and psychological study. Br Med J 1974; 3:666.
  13. Jaudes PK, Diamond LJ. The handicapped child and child abuse. Child Abuse Negl 1985; 9:341.
  14. Soeffing M. Abused children are exceptional children. Except Child 1975; 42:126.
  15. Pierce MC, Bertocci GE, Janosky JE, et al. Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics 2005; 115:1712.
  16. Hettler J, Greenes DS. Can the initial history predict whether a child with a head injury has been abused? Pediatrics 2003; 111:602.
  17. Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics 1977; 60:533.
  18. Nimityongskul P, Anderson LD. The likelihood of injuries when children fall out of bed. J Pediatr Orthop 1987; 7:184.
  19. Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics 1993; 92:125.
  20. Peters ML, Starling SP, Barnes-Eley ML, Heisler KW. The presence of bruising associated with fractures. Arch Pediatr Adolesc Med 2008; 162:877.
  21. Mathew MO, Ramamohan N, Bennet GC. Importance of bruising associated with paediatric fractures: prospective observational study. BMJ 1998; 317:1117.
  22. Eastwood D. Breaks without bruises. Are common and can't be said to rule out non-accidental injury. BMJ 1998; 317:1095.
  23. Paterson C. Bruising associated with paediatric fractures. Each case should be treated individually. BMJ 1999; 318:734.
  24. Paterson CR. Child abuse or copper deficiency? Br Med J (Clin Res Ed) 1987; 295:213.
  25. Taitz LS. Child abuse and metabolic bone disease: are they often confused? BMJ 1991; 302:1244.
  26. Merten DF, Radkowski MA, Leonidas JC. The abused child: a radiological reappraisal. Radiology 1983; 146:377.
  27. Section on Radiology, American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics 2009; 123:1430.
  28. Ablin DS, Sane SM. Non-accidental injury: confusion with temporary brittle bone disease and mild osteogenesis imperfecta. Pediatr Radiol 1997; 27:111.
  29. American College of Radiology. ACR appropriateness criteria. Suspected physical abuse--child. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/SuspectedPhysicalAbuseChild.pdf (Accessed on August 06, 2012).
  30. Offiah A, van Rijn RR, Perez-Rossello JM, Kleinman PK. Skeletal imaging of child abuse (non-accidental injury). Pediatr Radiol 2009; 39:461.
  31. British Society of Paediatric Radiology. Standard for skeletal surveys in suspected non-accidental injury (NAI) in children. Available at: www.bspr.org.uk/nai.htm. (Accessed on May 26, 2009).
  32. Hansen KK, Prince JS, Nixon GW. Oblique chest views as a routine part of skeletal surveys performed for possible physical abuse--is this practice worthwhile? Child Abuse Negl 2008; 32:155.
  33. Radkowski MA, Merten DF, Leonidas JC. The abused child: Criteria for the radiologic diagnosis. Radiographics 1983; 3:262.
  34. Duffy SO, Squires J, Fromkin JB, Berger RP. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics 2011; 127:e47.
  35. American Academy of Pediatrics Committee on Child Abuse and Neglect: Shaken baby syndrome: inflicted cerebral trauma. Pediatrics 1993; 92:872.
  36. Bennett BL, Chua MS, Care M, et al. Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal. BMC Res Notes 2011; 4:354.
  37. Kleinman PK, Nimkin K, Spevak MR, et al. Follow-up skeletal surveys in suspected child abuse. AJR Am J Roentgenol 1996; 167:893.
  38. Harper NS, Eddleman S, Lindberg DM, ExSTRA Investigators. The utility of follow-up skeletal surveys in child abuse. Pediatrics 2013; 131:e672.
  39. Zimmerman S, Makoroff K, Care M, et al. Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child Abuse Negl 2005; 29:1075.
  40. Cramer KE. Orthopedic aspects of child abuse. Pediatr Clin North Am 1996; 43:1035.
  41. Chapman S. The radiological dating of injuries. Arch Dis Child 1992; 67:1063.
  42. British Society of Paediatric Radiology. Standard for skeletal surveys in suspected non-accidental injury (NAI) in children. www.bspr.org.uk/nai.htm (Accessed on May 26, 2009).
  43. Chapman S. Radiological aspects of non-accidental injury. J R Soc Med 1990; 83:67.
  44. Drubach LA, Johnston PR, Newton AW, et al. Skeletal trauma in child abuse: detection with 18F-NaF PET. Radiology 2010; 255:173.
  45. Howard JL, Barron BJ, Smith GG. Bone scintigraphy in the evaluation of extraskeletal injuries from child abuse. Radiographics 1990; 10:67.
  46. Smith FW, Gilday DL, Ash JM, Green MD. Unsuspected costo-vertebral fractures demonstrated by bone scanning in the child abuse syndrome. Pediatr Radiol 1980; 10:103.
  47. Mandelstam SA, Cook D, Fitzgerald M, Ditchfield MR. Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child 2003; 88:387.
  48. Nimkin K, Kleinman PK. Imaging of child abuse. Radiol Clin North Am 2001; 39:843.
  49. Drubach LA, Sapp MV, Laffin S, Kleinman PK. Fluorine-18 NaF PET imaging of child abuse. Pediatr Radiol 2008; 38:776.
  50. Ludwig S. Child abuse. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott, Williams, & Wilkins, Philadelphia 2006. p.1761.
  51. Merten DF, Kirks DR, Ruderman RJ. Occult humeral epiphyseal fracture in battered infants. Pediatr Radiol 1981; 10:151.
  52. Merten DF, Carpenter BL. Radiologic imaging of inflicted injury in the child abuse syndrome. Pediatr Clin North Am 1990; 37:815.
  53. Rao P, Carty H. Non-accidental injury: review of the radiology. Clin Radiol 1999; 54:11.
  54. Smeets AJ, Robben SG, Meradji M. Sonographically detected costo-chondral dislocation in an abused child. A new sonographic sign to the radiological spectrum of child abuse. Pediatr Radiol 1990; 20:566.
  55. Kelloff J, Hulett R, Spivey M. Acute rib fracture diagnosis in an infant by US: a matter of child protection. Pediatr Radiol 2009; 39:70.
  56. Davie MW, Haddaway MJ. Bone mineral content and density in healthy subjects and in osteogenesis imperfecta. Arch Dis Child 1994; 70:331.
  57. Plotkin H, Rauch F, Bishop NJ, et al. Pamidronate treatment of severe osteogenesis imperfecta in children under 3 years of age. J Clin Endocrinol Metab 2000; 85:1846.
  58. Zionts LE, Nash JP, Rude R, et al. Bone mineral density in children with mild osteogenesis imperfecta. J Bone Joint Surg Br 1995; 77:143.
  59. Flaherty EG, Perez-Rossello JM, Levine MA, et al. Evaluating children with fractures for child physical abuse. Pediatrics 2014; 133:e477.
  60. Galleno H, Oppenheim WL. The battered child syndrome revisited. Clin Orthop Relat Res 1982; :11.
  61. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. Br Med J (Clin Res Ed) 1986; 293:100.
  62. Beals RK, Tufts E. Fractured femur in infancy: the role of child abuse. J Pediatr Orthop 1983; 3:583.
  63. O'Neill JA Jr, Meacham WF, Griffin JP, Sawyers JL. Patterns of injury in the battered child syndrome. J Trauma 1973; 13:332.
  64. Thomas SA, Rosenfield NS, Leventhal JM, Markowitz RI. Long-bone fractures in young children: distinguishing accidental injuries from child abuse. Pediatrics 1991; 88:471.
  65. Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ 2008; 337:a1518.
  66. Carty HM. Fractures caused by child abuse. J Bone Joint Surg Br 1993; 75:849.
  67. Rivara FP, Bergman AB, LoGerfo JP, Weiss NS. Epidemiology of childhood injuries. II. Sex differences in injury rates. Am J Dis Child 1982; 136:502.
  68. American Academy of Orthopaedic Surgeons. Treatment of pediatric diaphyseal femur fractures. Guideline and evidence report. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2009. www.aaos.org/Research/guidelines/PDFFguideline.asp (Accessed on September 30, 2009).
  69. Tarantino CA, Dowd MD, Murdock TC. Short vertical falls in infants. Pediatr Emerg Care 1999; 15:5.
  70. Hedlund R, Lindgren U. The incidence of femoral shaft fractures in children and adolescents. J Pediatr Orthop 1986; 6:47.
  71. Gross RH, Stranger M. Causative factors responsible for femoral fractures in infants and young children. J Pediatr Orthop 1983; 3:341.
  72. McClelland CQ, Heiple KG. Fractures in the first year of life. A diagnostic dilemma. Am J Dis Child 1982; 136:26.
  73. Blakemore LC, Loder RT, Hensinger RN. Role of intentional abuse in children 1 to 5 years old with isolated femoral shaft fractures. J Pediatr Orthop 1996; 16:585.
  74. Rex C, Kay PR. Features of femoral fractures in nonaccidental injury. J Pediatr Orthop 2000; 20:411.
  75. Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop 2000; 20:475.
  76. Shaw BA, Murphy KM, Shaw A, et al. Humerus shaft fractures in young children: accident or abuse? J Pediatr Orthop 1997; 17:293.
  77. Strait RT, Siegel RM, Shapiro RA. Humeral fractures without obvious etiologies in children less than 3 years of age: when is it abuse? Pediatrics 1995; 96:667.
  78. Loder RT, Bookout C. Fracture patterns in battered children. J Orthop Trauma 1991; 5:428.
  79. Leonidas JC. Skeletal trauma in the child abuse syndrome. Pediatr Ann 1983; 12:875.
  80. Pierce MC, Bertocci GE, Vogeley E, Moreland MS. Evaluating long bone fractures in children: a biomechanical approach with illustrative cases. Child Abuse Negl 2004; 28:505.
  81. Mellick LB, Milker L, Egsieker E. Childhood accidental spiral tibial (CAST) fractures. Pediatr Emerg Care 1999; 15:307.
  82. Scherl SA, Miller L, Lively N, et al. Accidental and nonaccidental femur fractures in children. Clin Orthop Relat Res 2000; :96.
  83. Radkowski MA, Merten DF, Leonidas JC. The abused child: Criteria for the radiologic diagnosis. Radiographics 1983; 3:262.
  84. Stewart GM, Rosenberg NM. Conditions mistaken for child abuse: Part I. Pediatr Emerg Care 1996; 12:116.
  85. Lazoritz S, Baldwin S, Kini N. The Whiplash Shaken Infant Syndrome: has Caffey's syndrome changed or have we changed his syndrome? Child Abuse Negl 1997; 21:1009.
  86. Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediatrics 1974; 54:396.
  87. Caffey J. On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child 1972; 124:161.
  88. Thompson A, Bertocci G, Kaczor K, et al. Biomechanical investigation of the classic metaphyseal lesion using an immature porcine model. AJR Am J Roentgenol 2015; 204:W503.
  89. Arkader A, Friedman JE, Warner WC Jr, Wells L. Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age. J Pediatr Orthop 2007; 27:751.
  90. Kleinman PK, Marks SC Jr. Relationship of the subperiosteal bone collar to metaphyseal lesions in abused infants. J Bone Joint Surg Am 1995; 77:1471.
  91. Kleinman PK, Marks SC, Blackbourne B. The metaphyseal lesion in abused infants: a radiologic-histopathologic study. AJR Am J Roentgenol 1986; 146:895.
  92. Grant P, Mata MB, Tidwell M. Femur fracture in infants: a possible accidental etiology. Pediatrics 2001; 108:1009.
  93. Lysack JT, Soboleski D. Classic metaphyseal lesion following external cephalic version and cesarean section. Pediatr Radiol 2003; 33:422.
  94. Grayev AM, Boal DK, Wallach DM, Segal LS. Metaphyseal fractures mimicking abuse during treatment for clubfoot. Pediatr Radiol 2001; 31:559.
  95. Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. J Trauma 1990; 30:695.
  96. Strouse PJ, Owings CL. Fractures of the first rib in child abuse. Radiology 1995; 197:763.
  97. Spevak MR, Kleinman PK, Belanger PL, et al. Cardiopulmonary resuscitation and rib fractures in infants. A postmortem radiologic-pathologic study. JAMA 1994; 272:617.
  98. Betz P, Liebhardt E. Rib fractures in children--resuscitation or child abuse? Int J Legal Med 1994; 106:215.
  99. Feldman KW, Brewer DK. Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics 1984; 73:339.
  100. Barsness KA, Cha ES, Bensard DD, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma 2003; 54:1107.
  101. Cadzow SP, Armstrong KL. Rib fractures in infants: red alert! The clinical features, investigations and child protection outcomes. J Paediatr Child Health 2000; 36:322.
  102. Bulloch B, Schubert CJ, Brophy PD, et al. Cause and clinical characteristics of rib fractures in infants. Pediatrics 2000; 105:E48.
  103. Paine CW, Fakeye O, Christian CW, Wood JN. Prevalence of Abuse Among Young Children With Rib Fractures: A Systematic Review. Pediatr Emerg Care 2016.
  104. Kleinman PK, Marks SC Jr, Nimkin K, et al. Rib fractures in 31 abused infants: postmortem radiologic-histopathologic study. Radiology 1996; 200:807.
  105. Gabos PG, Tuten HR, Leet A, Stanton RP. Fracture-dislocation of the lumbar spine in an abused child. Pediatrics 1998; 101:473.
  106. Akbarnia BA. Pediatric spine fractures. Orthop Clin North Am 1999; 30:521.
  107. Kleinman PK, Zito JL. Avulsion of the spinous processes caused by infant abuse. Radiology 1984; 151:389.
  108. Diamond P, Hansen CM, Christofersen MR. Child abuse presenting as a thoracolumbar spinal fracture dislocation: a case report. Pediatr Emerg Care 1994; 10:83.
  109. Thomas NH, Robinson L, Evans A, Bullock P. The floppy infant: a new manifestation of nonaccidental injury. Pediatr Neurosurg 1995; 23:188.
  110. Kleinman PK, Shelton YA. Hangman's fracture in an abused infant: imaging features. Pediatr Radiol 1997; 27:776.
  111. Rooks VJ, Sisler C, Burton B. Cervical spine injury in child abuse: report of two cases. Pediatr Radiol 1998; 28:193.
  112. Carrion WV, Dormans JP, Drummond DS, Christofersen MR. Circumferential growth plate fracture of the thoracolumbar spine from child abuse. J Pediatr Orthop 1996; 16:210.
  113. Starling SP, Heller RM, Jenny C. Pelvic fractures in infants as a sign of physical abuse. Child Abuse Negl 2002; 26:475.
  114. Ablin DS, Greenspan A, Reinhart MA. Pelvic injuries in child abuse. Pediatr Radiol 1992; 22:454.
  115. Nimkin K, Spevak MR, Kleinman PK. Fractures of the hands and feet in child abuse: imaging and pathologic features. Radiology 1997; 203:233.
  116. McGraw EP, Pless JE, Pennington DJ, White SJ. Postmortem radiography after unexpected death in neonates, infants, and children: should imaging be routine? AJR Am J Roentgenol 2002; 178:1517.
  117. Krishnan J, Barbour PJ, Foster BK. Patterns of osseous injuries and psychosocial factors affecting victims of child abuse. Aust N Z J Surg 1990; 60:447.
  118. Morzaria S, Walton JM, MacMillan A. Inflicted esophageal perforation. J Pediatr Surg 1998; 33:871.
  119. Conway JJ, Collins M, Tanz RR, et al. The role of bone scintigraphy in detecting child abuse. Semin Nucl Med 1993; 23:321.
  120. Sty JR, Starshak RJ. The role of bone scintigraphy in the evaluation of the suspected abused child. Radiology 1983; 146:369.