From the Guidelines
Pathognomonic fractures for child abuse include metaphyseal corner or bucket-handle fractures, posterior rib fractures, scapular fractures, spinous process fractures, and sternal fractures, as these fractures have high specificity for abuse due to the unique biomechanical forces required to produce them 1.
Fracture Patterns
These fractures are highly suggestive of child abuse because they rarely occur in accidental injuries but are consistent with the handling patterns seen in abuse cases.
- Metaphyseal corner fractures occur at the growth plate of long bones and have a characteristic appearance of a small bone fragment at the corner of the metaphysis, resulting from violent pulling or twisting forces applied to a child's extremities.
- Posterior rib fractures, especially multiple and bilateral ones, strongly suggest abuse as they typically occur from anteroposterior compression of the chest, such as during violent squeezing.
- Scapular, spinous process, and sternal fractures are rare in accidental trauma due to their protected anatomical positions, making them highly suspicious for abuse when present.
Age and Development Considerations
The child's age and level of development should also be considered, as approximately 80% of all fractures caused by child abuse occur in children younger than 18 months, and approximately one-quarter of fractures in children younger than 1 year are caused by child abuse 1.
Specificity of Fractures
The specificity of these fractures for abuse is high, with certain fractures having higher specificity than others, as shown in the table below:
| High specificity | Moderate specificity | Common, but low specificity |
|---|---|---|
| CMLs | Multiple fractures, especially bilateral | Subperiosteal new bone formation |
| Rib fractures, especially posteromedial | Fractures of different ages | Clavicular fractures |
| Scapular fractures | Epiphyseal separations | Long-bone shaft fractures |
| Spinous process fractures | Vertebral body fractures and subluxations | Linear skull fractures |
| Sternal fractures | ||
| According to the most recent and highest quality study, the presence of these fractures should raise suspicion for child abuse and prompt further evaluation and investigation 1. |
From the Research
Fractures Indicative of Child Abuse
The following fractures are considered pathognomonic for child abuse:
- Metaphyseal corner fractures and bucket-handle fractures 2, 3, 4
- Fractures of the ribs, particularly posterior rib fractures 2, 3, 5
- Fractures of the scapula, lateral end of the clavicle, vertebrae, and complex skull fractures 2
- Multiple fractures, particularly at various stages of healing 2, 3
Specificity of Fractures for Child Abuse
Certain fractures have a high specificity for child abuse, including:
- Isolated or multiple rib fractures, irrespective of location 2
- Metaphyseal corner fractures, also known as "corner fractures" 3, 4
- Posterior rib fractures 3, 5
- Fractures of the scapula, lateral end of the clavicle, vertebrae, and complex skull fractures 2
Differential Diagnosis
It is essential to consider alternative causes for these fractures, such as: