How to Diagnose a Broken Bone in a Child

Start with plain X-rays of the area of concern—this is your first-line diagnostic test for any suspected pediatric fracture. 1

Initial Diagnostic Approach

Obtain standard three-view radiographs of the affected area as the primary diagnostic modality 1
Plain X-rays remain the gold standard initial test, though negative films don't completely rule out a nondisplaced fracture 1
In children over 2 years old who can verbalize, focus imaging on the specific area of pain or clinical concern 2

Consider bedside ultrasound as an adjunct tool—it has 89% sensitivity and 100% specificity for detecting long bone fractures in children 3
Ultrasound is particularly useful because it can visualize the cartilaginous portions of pediatric bones that may not show up on X-ray 4, 5
Ultrasound works by reflecting waves off cortical bone, making fracture lines easily visible 5
If symptoms persist despite negative X-rays and ultrasound is unavailable, bone scintigraphy or MRI can be considered, though these require sedation and are rarely necessary 1

Any fracture in a child under 1 year of age, especially in non-walking infants, should raise immediate suspicion for physical abuse. 1, 6

When abuse is suspected, you must:

Perform a complete skeletal survey immediately in all children under 2 years of age 6, 7
The skeletal survey must include 21 images: frontal and lateral skull views, lateral cervical and thoracolumbar spine, oblique rib views, and single frontal views of all long bones, hands, feet, chest, and abdomen 6, 7
Oblique rib views are essential—rib fractures may be the only skeletal finding in 30% of physically abused infants 6
Repeat the skeletal survey in 2-3 weeks if initial findings are abnormal, equivocal, or clinical suspicion remains high—this detects additional fractures in 9-12% of cases 6, 7

Maintain a low threshold for head CT in children under 12 months with suspected abuse, even without neurologic symptoms 6, 7
29-37% of children under 1 year with suspected abuse but no clinical signs of head injury have positive neuroimaging findings (subdural hematoma, epidural hematoma, cerebral edema) 6, 7
Use unenhanced CT as the initial study for suspected intracranial injury 6, 7

Never dismiss fractures in pre-walking or newly walking children without careful evaluation—fractures in non-ambulatory infants are highly concerning for abuse 1, 6
Don't rely on the presence or absence of bruising to determine if abuse occurred—most children with fractures don't have associated bruising 6
Never substitute bone scan for skeletal survey as the primary imaging—bone scan is only complementary and should be used when skeletal survey is negative but suspicion remains 6
Don't assume negative initial radiographs exclude fracture—particularly in toddlers, follow-up imaging or clinical reassessment may be necessary 1

When fractures occur without adequate trauma history, consider:

Osteogenesis imperfecta (OI) if clinical features suggest brittle bone disease 2
Blue sclerae occur normally in infants under 12 months, so this finding alone doesn't confirm OI 2
If OI is suspected and clinical exam is not definitive, biochemical collagen testing or DNA testing for COL1A1/COL1A2 mutations may be warranted 2
Laboratory testing has identified OI in children who were not diagnosed on clinical examination alone 2

Report to child protective services based on reasonable suspicion alone—you don't need certainty or proof. 7

All 50 states mandate reporting when suspecting child abuse or neglect 7
Document thoroughly: exact injury descriptions with measurements, verbatim caregiver statements about mechanism, timeline discrepancies, all physical exam findings, and complete imaging results 7