Fractures and Skeletal Injuries

  • Angela BachimEmail author
  • Nancy S. Harper


The identification of a skeletal injury may be the first indication of abuse. Estimates of the frequency of fractures in abused children vary from approximately 10–50%, depending on the population studied, the type of diagnostic imaging used to detect fractures, and the age of the patients seen (Ebbin et al., Am J Dis Child 118(4):660–667, 1969; Herndon, J Pediatr Orthop 3(1):73–76, 1983; Leventhal et al., Am J Dis Child 147(1):87–92, 1993). Recently, large population-based studies have been used to estimate the incidence of inflicted skeletal trauma. While the majority of fractures are still attributed to falls, child abuse accounts for 12% of fractures in children less than 36 months of age (Leventhal et al., Pediatrics 122(3):599–604, 2008). Infants and young children sustain significantly more abusive skeletal injuries than do older children, with the majority of inflicted fractures occurring in children under 12 months of age (Leventhal et al., Pediatrics 122(3):599–604, 2008; Leventhal et al., Pediatrics 126(1):e104–e115, 2010; Loder and Feinberg, J Pediatr Orthop 27(4):421–426, 2007; Sibert et al., Child Abuse Negl 26(3):267–276, 2002). Fractures of the ribs, arm, and leg account for over half of the inflicted skeletal injuries in young children (Leventhal et al., Pediatrics 122(3):599–604, 2008; Starling et al., Child Abuse Negl 31(9):993–999, 2007). These injuries are often occult and detected only with detailed skeletal imaging.


Fractures Skeletal injuries Bone anatomy Skull fracture 


  1. Ablin, D. S., Greenspan, A., Reinhart, M., & Grix, A. (1990). Differentiation of child abuse from osteogenesis imperfecta. AJR American Journal of Roentgenology, 154(5), 1035–1046.CrossRefPubMedPubMedCentralGoogle Scholar
  2. American College of Radiology. (2016). ACR-SPR practice parameter for the performance and interpretation of skeletal surveys in children, 1–9. Retrieved from
  3. Amir, J., Katz, K., Grunebaum, M., Yosipovich, Z., Wielunsky, E., & Reisner, S. (1988). Fractures in premature infants. Journal of Pediatric Orthopaedics, 8(1), 41–44.CrossRefPubMedPubMedCentralGoogle Scholar
  4. Apkon, S. D., Fenton, L., & Coll, J. R. (2009). Bone mineral density in children with myelomeningocele. Developmental Medicine & Child Neurology, 51(1), 63–67.CrossRefGoogle Scholar
  5. ACR Appropriateness Criteria: Suspected Physical Abuse-Child. (2017). Journal of the American College of Radiology, 14(5S), S338–S349. doi:
  6. Arnholz, D., Hymel, K. P., Hay, T. C., & Jenny, C. (1998). Bilateral pediatric skull fractures: Accident or abuse? Journal of Trauma and Acute Care Surgery, 45(1), 172–174.CrossRefGoogle Scholar
  7. Astley, R. (1979). Metaphyseal fractures in osteogenesis imperfecta. British Journal of Radiology, 52, 441–443.CrossRefPubMedPubMedCentralGoogle Scholar
  8. Bainbridge, J., Huey, B., & Harrison, S. (2015). Should bone scintigraphy be used as a routine adjunct to skeletal survey in the imaging of non-accidental injury? A 10 year review of reports in a single centre. Clinical Radiology, 70(8), e83–e89.CrossRefPubMedPubMedCentralGoogle Scholar
  9. Barber, I., Perez-Rossello, J. M., Wilson, C. R., Silvera, M. V., & Kleinman, P. K. (2013). Prevalence and relevance of pediatric spinal fractures in suspected child abuse. Pediatric Radiology, 43(11), 1507–1515.CrossRefPubMedPubMedCentralGoogle Scholar
  10. Barber, I., Perez-Rossello, J. M., Wilson, C. R., & Kleinman, P. K. (2015). The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatric Radiology, 45(1), 69–80. Scholar
  11. Barsness, K. A., Cha, E.-S., Bensard, D. D., Calkins, C. M., Partrick, D. A., Karrer, F. M., & Strain, J. D. (2003). The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. Journal of Trauma and Acute Care Surgery, 54(6), 1107–1110.CrossRefGoogle Scholar
  12. Bennett, B. L., Chua, M. S., Care, M., Kachelmeyer, A., & Mahabee-Gittens, M. (2011). Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal. BMC Research Notes, 4(1), 354.CrossRefPubMedPubMedCentralGoogle Scholar
  13. Billmire, M. E., & Myers, P. A. (1985). Serious head injury in infants: Accident or abuse? Pediatrics, 75(2), 340–342.PubMedPubMedCentralGoogle Scholar
  14. Bixby, S. D., Abo, A., & Kleinman, P. K. (2011). High-impact trauma causing multiple posteromedial rib fractures in a child. Pediatric Emergency Care, 27(3), 218–219.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Bixby, S. D., Wilson, C. R., Barber, I., & Kleinman, P. K. (2014). Ischial apophyseal fracture in an abused infant. Pediatric Radiology, 44(9), 1175–1178.CrossRefPubMedPubMedCentralGoogle Scholar
  16. Brink, F. W., Gold, D. L., Adler, B., & Letson, M. M. (2017). Distraction injury of the thoracic spine with spinal cord transection and vascular injury in a 5-week-old infant boy: A case of child physical abuse. Pediatric Emergency Care, 33(3), 192–197.CrossRefPubMedPubMedCentralGoogle Scholar
  17. Bronicki, L. M., Stevenson, R. E., & Spranger, J. W. (2015). Beyond osteogenesis imperfecta: Causes of fractures during infancy and childhood. Paper presented at the American Journal of Medical Genetics Part C: Seminars in Medical Genetics.Google Scholar
  18. Bulloch, B., Schubert, C. J., Brophy, P. D., Johnson, N., Reed, M. H., & Shapiro, R. A. (2000). Cause and clinical characteristics of rib fractures in infants. Pediatrics, 105(4), e48–e48.CrossRefPubMedPubMedCentralGoogle Scholar
  19. Caffey, J. (1957). Some traumatic lesions in growing bones other than fractures and dislocations: Clinical and radiological features—The Mackenzie Davidson Memorial Lecture. British Journal of Radiology, 30(353), 225–238.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Capra, L., Levin, A. V., Howard, A., & Shouldice, M. (2013). Characteristics of femur fractures in ambulatory young children. Emergency Medicine Journal, 30(9), 749–753.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Carroll, D. M., Doria, A. S., & Paul, B. S. (2007). Clinical-radiological features of fractures in premature infants – A review. Journal of Perinatal Medicine, 35(5), 366–375.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Caviglia, H., Garrido, C. P., Palazzi, F. F., & Meana, N. V. (2005). Pediatric fractures of the humerus. Clinical Orthopaedics and Related Research, 432, 49–56.CrossRefGoogle Scholar
  23. Chapman, S. (1992). The radiological dating of injuries. Archives of Disease in Childhood, 67(9), 1063.CrossRefPubMedPubMedCentralGoogle Scholar
  24. Chapman, T., Sugar, N., Done, S., Marasigan, J., Wambold, N., & Feldman, K. (2010). Fractures in infants and toddlers with rickets. Pediatric Radiology, 40(7), 1184–1189.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Choudhary, A. K., Jha, B., Boal, D. K., & Dias, M. (2010). Occipital sutures and its variations: The value of 3D-CT and how to differentiate it from fractures using 3D-CT? Surgical and Radiologic Anatomy, 32(9), 807–816. Scholar
  26. Christian, C. W., & Committee on Child Abuse and Neglect, American Academy of Pediatrics. (2015). The evaluation of suspected child physical abuse. Pediatrics, 135(5), e1337–e1354. Scholar
  27. Coats, B., & Margulies, S. S. (2008). Potential for head injuries in infants from low-height falls. Journal of Neurosurgery: Pediatrics, 2(5), 321–330.PubMedPubMedCentralGoogle Scholar
  28. Congdon, P., Horsman, A., Ryan, S., Truscott, J., & Durward, H. (1990). Spontaneous resolution of bone mineral depletion in preterm infants. Archives of Disease in Childhood, 65(10 Spec No):1038–1042.Google Scholar
  29. Culotta, P. A., Crowe, J. E., Tran, Q.-A., Jones, J. Y., Mehollin-Ray, A. R., Tran, H. B., et al. (2017). Performance of computed tomography of the head to evaluate for skull fractures in infants with suspected non-accidental trauma. Pediatric Radiology, 47(1), 74–81.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Dabezies, E. J., & Warren, P. D. (1997). Fractures in very low birth weight infants with rickets. Clinical Orthopaedics and Related Research, 335, 233–239.Google Scholar
  31. Darling, S. E., Done, S. L., Friedman, S. D., & Feldman, K. W. (2014). Frequency of intrathoracic injuries in children younger than 3 years with rib fractures. Pediatric Radiology, 44(10), 1230–1236.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Davis, B. (2010). Caffey disease. Available at eMedicine Radiology. Retrieved from
  33. Day, F., Clegg, S., McPhillips, M., & Mok, J. (2006). A retrospective case series of skeletal surveys in children with suspected non-accidental injury. Journal of Clinical Forensic Medicine, 13, 55–59.CrossRefPubMedPubMedCentralGoogle Scholar
  34. Deye, K. P., Berger, R. P., Lindberg, D. M., & Investigators, E. S. T. R. A. (2013). Occult abusive injuries in infants with apparently isolated skull fractures. Journal of Trauma and Acute Care Surgery, 74(6), 1553–1558.CrossRefPubMedPubMedCentralGoogle Scholar
  35. Drubach, L. A., Johnston, P. R., Newton, A. W., Perez-Rossello, J. M., Grant, F. D., & Kleinman, P. K. (2010). Skeletal trauma in child abuse: Detection with 18F-NaF PET. Radiology, 255(1), 173–181.CrossRefPubMedPubMedCentralGoogle Scholar
  36. Duffy, S. O., Squires, J., Fromkin, J. B., & Berger, R. P. (2011). Use of skeletal surveys to evaluate for physical abuse: Analysis of 703 consecutive skeletal surveys. Pediatrics, 127(1), e47–e52. Scholar
  37. Duhaime, A.-C., Alario, A., Lewander, W., Schut, L., Sutton, L., Seidl, T., et al. (1992). Head injury in very young children: Mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics, 90(2), 179–185.PubMedPubMedCentralGoogle Scholar
  38. Ebbin, A. J., Gollub, M. H., Stein, A. M., & Wilson, M. G. (1969). Battered child syndrome at the Los Angeles County General Hospital. American Journal of Diseases of Children, 118(4), 660–667.PubMedPubMedCentralGoogle Scholar
  39. Ersahin, Y., Gülmen, V., Palali, I., & Mutluer, S. (2000). Growing skull fractures (craniocerebral erosion). Neurosurgical Review, 23(3), 139–144.CrossRefPubMedPubMedCentralGoogle Scholar
  40. Fadell, M., Miller, A., Trefan, L., Weinman, J., Stewart, J., Hayes, K., & Maguire, S. (2017). Radiological features of healing in newborn clavicular fractures. European Radiology, 27(5), 2180–2187.CrossRefPubMedPubMedCentralGoogle Scholar
  41. Fagen, K. E., Shalaby-Rana, E., & Jackson, A. M. (2015). Frequency of skeletal injuries in children with inflicted burns. Pediatric Radiology, 45(3), 396–401. Scholar
  42. Farrell, C., Rubin, D. M., Downes, K., Dormans, J., & Christian, C. W. (2012). Symptoms and time to medical care in children with accidental extremity fractures. Pediatrics, 129(1), e128–e133. Scholar
  43. Fiser, R. H., Kaplan, J., & Holder, J. C. (1972). Congenital syphilis mimicking the battered child syndrome: How does one tell them apart? Clinical Pediatrics, 11(5), 305–307.CrossRefPubMedPubMedCentralGoogle Scholar
  44. Flaherty, E. G., Perez-Rossello, J. M., Levine, M. A., Hennrikus, W. L., et al. (2014). Evaluating children with fractures for child physical abuse. Pediatrics, 133(2), e477–e489.CrossRefPubMedPubMedCentralGoogle Scholar
  45. Forin, V. (2010). Osteogenesis inperfecta type 5. Retrieved from
  46. Gahagan, S., & Rimsza, M. E. (1991). Child abuse or osteogenesis imperfecta: How can we tell? Pediatrics, 88(5), 987–992.PubMedPubMedCentralGoogle Scholar
  47. Garcia, V. F., Gotschall, C. S., Eichelberger, M. R., & Bowman, L. M. (1990). Rib fractures in children: A marker of severe trauma. Journal of Trauma and Acute Care Surgery, 30(6), 695–700.CrossRefGoogle Scholar
  48. George, C. L., Harper, N. S., Guillaume, D., Cayci, Z., & Nascene, D. (2017). Vascular channel mimicking a skull fracture. Journal of Pediatrics, 181, 326–326.CrossRefPubMedPubMedCentralGoogle Scholar
  49. Glaser, K. (1949). Double contour, cupping and spurring in roentgenograms of long bones in infants. American Journal of Roentgenology and Radium Therapy, 61(4), 482.PubMedPubMedCentralGoogle Scholar
  50. Glorieux, F. H. (2008). Osteogenesis imperfecta. Best Practice & Research Clinical Rheumatology, 22(1), 85–100.CrossRefGoogle Scholar
  51. Golriz, F., Donnelly, L. F., Devaraj, S., & Krishnamurthy, R. (2017). Modern American scurvy—Experience with vitamin C deficiency at a large children’s hospital. Pediatric Radiology, 47(2), 214–220.CrossRefPubMedPubMedCentralGoogle Scholar
  52. Gordon, C. M., Feldman, H. A., Sinclair, L., Williams, A. L., Kleinman, P. K., Perez-Rossello, J., & Cox, J. E. (2008). Prevalence of vitamin D deficiency among healthy infants and toddlers. Archives of Pediatrics & Adolescent Medicine, 162(6), 505–512.CrossRefGoogle Scholar
  53. Grayev, A. M., Boal, D. K., Wallach, D. M., & Segal, L. S. (2001). Metaphyseal fractures mimicking abuse during treatment for clubfoot. Pediatric Radiology, 31(8), 559–563.CrossRefPubMedPubMedCentralGoogle Scholar
  54. Greeley, C. S., Donaruma-Kwoh, M., Vettimattam, M., Lobo, C., Williard, C., & Mazur, L. (2013). Fractures at diagnosis in infants and children with osteogenesis imperfecta. Journal of Pediatric Orthopaedics, 33(1), 32.CrossRefPubMedPubMedCentralGoogle Scholar
  55. Hansen, K. K., Prince, J. S., & Nixon, G. W. (2008). Oblique chest views as a routine part of skeletal surveys performed for possible physical abuse—Is this practice worthwhile? Child Abuse & Neglect, 32(1), 155–159.CrossRefGoogle Scholar
  56. Hansen, K. K., Keeshin, B. R., Flaherty, E., Newton, A., Passmore, S., Prince, J., & Campbell, K. A. (2014). Sensitivity of the limited view follow-up skeletal survey. Pediatrics, 134(2), 242–248.CrossRefPubMedPubMedCentralGoogle Scholar
  57. Harper, N. S., Eddleman, S., Lindberg, D. M., & for the ExSTRA Investigators. (2013). The utility of follow-up skeletal surveys in child abuse. Pediatrics, 131(3), e672–e678. Scholar
  58. Helfer, R. E., Scheurer, S. L., Alexander, R., Reed, J., & Slovis, T. L. (1984). Trauma to the bones of small infants from passive exercise: A factor in the etiology of child abuse. Journal of Pediatrics, 104(1), 47–50.CrossRefPubMedPubMedCentralGoogle Scholar
  59. Herndon, W. A. (1983). Child abuse in a military population. Journal of Pediatric Orthopaedics, 3(1), 73–76.CrossRefPubMedPubMedCentralGoogle Scholar
  60. Hiss, J., & Kahana, T. (1995). The medicolegal implications of bilateral cranial fractures in infants. Journal of Trauma and Acute Care Surgery, 38(1), 32–34.CrossRefGoogle Scholar
  61. Hobbs, C. J. (1984). Skull fracture and the diagnosis of abuse. Archives of Disease in Childhood, 59(3), 246–252.CrossRefPubMedPubMedCentralGoogle Scholar
  62. Holck, P. (2005). What can a baby’s skull withstand? Testing the skull’s resistance on an anatomical preparation. Forensic Science International, 151(2), 187–191.CrossRefPubMedPubMedCentralGoogle Scholar
  63. Holick, M. F. (2007). Vitamin D deficiency. New England Journal of Medicine, 2007(357), 266–281.CrossRefGoogle Scholar
  64. Holick, M. F. (2009). Vitamin D status: Measurement, interpretation, and clinical application. Annals of Epidemiology, 19(2), 73–78.CrossRefPubMedPubMedCentralGoogle Scholar
  65. Horsman, A., Ryan, S., Congdon, P., Truscott, J., & James, J. (1989a). Osteopenia in extremely low birthweight infants. Archives of Disease in Childhood, 64(4 Spec No), 485–488.Google Scholar
  66. Horsman, A., Ryan, S., Congdon, P., Truscott, J., & Simpson, M. (1989b). Bone mineral accretion rate and calcium intake in preterm infants. Archives of Disease in Childhood, 64(7 Spec No), 910–918.Google Scholar
  67. Horsman, A., Ryan, S., Congdon, P., Truscott, J., & Simpson, M. (1989c). Bone mineral content and body size 65 to 100 weeks’ postconception in preterm and full term infants. Archives of Disease in Childhood, 64(11), 1579–1586.CrossRefPubMedPubMedCentralGoogle Scholar
  68. Ibrahim, N. G., Wood, J., Margulies, S. S., & Christian, C. W. (2012). Influence of age and fall type on head injuries in infants and toddlers. International Journal of Developmental Neuroscience, 30(3), 201–206. Scholar
  69. Islam, O., Soboleski, D., Symons, S., Davidson, L., Ashworth, M., & Babyn, P. (2000). Development and duration of radiographic signs of bone healing in children. American Journal of Roentgenology, 175(1), 75–78.CrossRefPubMedPubMedCentralGoogle Scholar
  70. John, S. D., Moorthy, C. S., & Swischuk, L. E. (1997). Expanding the concept of the toddler’s fracture. Radiographics, 17(2), 367–376.CrossRefPubMedPubMedCentralGoogle Scholar
  71. Kemp, A. M., Dunstan, F., Harrison, S., Morris, S., Mann, M., Rolfe, K., et al. (2008). Patterns of skeletal fractures in child abuse: Systematic review. BMJ, 337, a1518.CrossRefPubMedPubMedCentralGoogle Scholar
  72. Kimberlin, D. W., Brady, M. T., Jackson, M. A., Long, S. S., eds (2018). Red Book: 2018 Report of the Committee on Infectious Diseases. American Academy of Pediatrics.Google Scholar
  73. Kleinman, P. K. (1990). Diagnostic imaging in infant abuse. AJR American Journal of Roentgenology, 155(4), 703–712.CrossRefPubMedPubMedCentralGoogle Scholar
  74. Kleinman, P. K. (2008). Problems in the diagnosis of metaphyseal fractures. Pediatric Radiology, 38(3), 388.CrossRefGoogle Scholar
  75. Kleinman, P. K. (2015). Diagnostic imaging of child abuse (3rd ed.). New York: Cambridge University Press.CrossRefGoogle Scholar
  76. Kleinman, P. K., & Marks, S. C. (1992). Vertebral body fractures in child abuse: Radiologic-histopathologic correlates. Investigative Radiology, 27(9), 715–722.CrossRefPubMedPubMedCentralGoogle Scholar
  77. Kleinman, P. K., & Marks, S. C., Jr. (1996a). A regional approach to classic metaphyseal lesions in abused infants: The distal tibia. AJR American Journal of Roentgenology, 166(5), 1207–1212.CrossRefPubMedPubMedCentralGoogle Scholar
  78. Kleinman, P. K., & Marks, S. C., Jr. (1996b). A regional approach to the classic metaphyseal lesion in abused infants: The proximal humerus. AJR American Journal of Roentgenology, 167(6), 1399–1403.CrossRefPubMedPubMedCentralGoogle Scholar
  79. Kleinman, P. K., & Marks, S. C., Jr. (1996c). A regional approach to the classic metaphyseal lesion in abused infants: The proximal tibia. AJR American Journal of Roentgenology, 166(2), 421–426.CrossRefPubMedPubMedCentralGoogle Scholar
  80. Kleinman, P. K., & Marks, S. C., Jr. (1998). A regional approach to the classic metaphyseal lesion in abused infants: The distal femur. AJR American Journal of Roentgenology, 170(1), 43–47.CrossRefPubMedPubMedCentralGoogle Scholar
  81. Kleinman, P. K., & Schlesinger, A. E. (1997). Mechanical factors associated with posterior rib fractures: Laboratory and case studies. Pediatric Radiology, 27(1), 87–91.CrossRefPubMedPubMedCentralGoogle Scholar
  82. Kleinman, P. K., & Spevak, M. R. (1992). Soft tissue swelling and acute skull fractures. Journal of Pediatrics, 121(5), 737–739.CrossRefPubMedPubMedCentralGoogle Scholar
  83. Kleinman, P. K., Marks, S., & Blackbourne, B. (1986). The metaphyseal lesion in abused infants: A radiologic-histopathologic study. American Journal of Roentgenology, 146(5), 895–905.CrossRefPubMedPubMedCentralGoogle Scholar
  84. Kleinman, P. K., Marks, S. C., Adams, V. I., & Blackbourne, B. D. (1988). Factors affecting visualization of posterior rib fractures in abused infants. American Journal of Roentgenology, 150(3), 635–638.CrossRefPubMedPubMedCentralGoogle Scholar
  85. Kleinman, P. K., Belanger, P. L., Karellas, A., & Spevak, M. R. (1991). Normal metaphyseal radiologic variants not to be confused with findings of infant abuse. AJR American Journal of Roentgenology, 156(4), 781–783.CrossRefPubMedPubMedCentralGoogle Scholar
  86. Kleinman, P. K., Marks, S. C., Spevak, M. R., & Richmond, J. M. (1992). Fractures of the rib head in abused infants. Radiology, 185(1), 119–123.CrossRefPubMedPubMedCentralGoogle Scholar
  87. Kleinman, P. K., Marks, S. C., Jr., Richmond, J. M., & Blackbourne, B. D. (1995). Inflicted skeletal injury: A postmortem radiologic-histopathologic study in 31 infants. American Journal of Roentgenology, 165, 647–650.CrossRefPubMedPubMedCentralGoogle Scholar
  88. Kleinman, P. K., Nimkin, K., Spevak, M. R., Rayder, S. M., Madansky, D. L., Shelton, Y. A., & Patterson, M. M. (1996). Follow-up skeletal surveys in suspected child abuse. AJR American Journal of Roentgenology, 167(4), 893–896.CrossRefPubMedPubMedCentralGoogle Scholar
  89. Kleinman, P. K., Perez-Rossello, J. M., Newton, A. W., Feldman, H. A., & Kleinman, P. L. (2011). Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. American Journal of Roentgenology, 197(4), 1005–1008.CrossRefPubMedPubMedCentralGoogle Scholar
  90. Kleinman, P. K., Morris, N. B., Makris, J., Moles, R. L., & Kleinman, P. L. (2013). Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse. American Journal of Roentgenology, 200(3), 641–644.CrossRefPubMedPubMedCentralGoogle Scholar
  91. Kogutt, M. S., Swischuk, L. E., & Fagan, C. J. (1974). Patterns of injury and significance of uncommon fractures in the battered child syndrome. American Journal of Roentgenology, 121(1), 143–149.CrossRefGoogle Scholar
  92. Krischer, J. P., Fine, E. G., Davis, J. H., & Nagel, E. L. (1987). Complications of cardiac resuscitation. Chest, 92(2), 287–291.CrossRefPubMedPubMedCentralGoogle Scholar
  93. Kwon, D. S., Spevak, M. R., Fletcher, K., & Kleinman, P. K. (2002). Physiologic subperiosteal new bone formation: Prevalence, distribution, and thickness in neonates and infants. American Journal of Roentgenology, 179(4), 985–988.CrossRefPubMedPubMedCentralGoogle Scholar
  94. Laskey, A. L., Stump, T. E., Hicks, R. A., & Smith, J. L. (2013). Yield of skeletal surveys in children ≤ 18 months of age presenting with isolated skull fractures. Journal of Pediatrics, 162(1), 86–89.CrossRefPubMedPubMedCentralGoogle Scholar
  95. Leventhal, J. M., Thomas, S. A., Rosenfield, N. S., & Markowitz, R. I. (1993). Fractures in young children: Distinguishing child abuse from unintentional injuries. American Journal of Diseases of Children, 147(1), 87–92.CrossRefPubMedPubMedCentralGoogle Scholar
  96. Leventhal, J. M., Martin, K. D., & Asnes, A. G. (2008). Incidence of fractures attributable to abuse in young hospitalized children: Results from analysis of a United States database. Pediatrics, 122(3), 599–604.CrossRefPubMedPubMedCentralGoogle Scholar
  97. Leventhal, J. M., Martin, K. D., & Asnes, A. G. (2010). Fractures and traumatic brain injuries: Abuse versus accidents in a US database of hospitalized children. Pediatrics, 126(1), e104–e115.CrossRefPubMedPubMedCentralGoogle Scholar
  98. Lindberg, D. M., Shapiro, R. A., Laskey, A. L., Pallin, D. J., Blood, E. A., Berger, R. P., & Investigators, E. S. T. R. A. (2012). Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics, 130(2), 193–201.CrossRefPubMedPubMedCentralGoogle Scholar
  99. Lindberg, D. M., Harper, N. S., Laskey, A. L., Berger, R. P., & ExSTRA Investigators. (2013). Prevalence of abusive fractures of the hands, feet, spine, or pelvis on skeletal survey: Perhaps “uncommon” is more common than suggested. Pediatric Emergency Care, 29(1), 26–29.CrossRefPubMedPubMedCentralGoogle Scholar
  100. Lindberg, D. M., Berger, R. P., Reynolds, M. S., Alwan, R. M., Harper, N. S., & Examining Siblings to Recognize Abuse Investigators. (2014). Yield of skeletal survey by age in children referred to abuse specialists. Journal of Pediatrics, 164(6), 1268–1273 e1261. Scholar
  101. Loder, R. T., & Feinberg, J. R. (2007). Orthopaedic injuries in children with nonaccidental trauma: Demographics and incidence from the 2000 kids’ inpatient database. Journal of Pediatric Orthopaedics, 27(4), 421–426.CrossRefPubMedPubMedCentralGoogle Scholar
  102. Lysack, J. T., & Soboleski, D. (2003). Classic metaphyseal lesion following external cephalic version and cesarean section. Pediatric Radiology, 33(6), 422–424.CrossRefPubMedPubMedCentralGoogle Scholar
  103. Maguire, S., Mann, M., John, N., Ellaway, B., Sibert, J. R., Kemp, A. M., & Welsh Child Protection Systematic Review Group. (2006). Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review. Child Abuse & Neglect, 30(7), 739–751.CrossRefGoogle Scholar
  104. Maguire, S., Cowley, L., Mann, M., & Kemp, A. (2013). What does the recent literature add to the identification and investigation of fractures in child abuse: An overview of review updates 2005–2013. Evidence-Based Child Health: A Cochrane Review Journal, 8(5), 2044–2057.CrossRefGoogle Scholar
  105. Marine, M. B., Corea, D., Steenburg, S. D., Wanner, M., Eckert, G. J., Jennings, S. G., & Karmazyn, B. (2014). Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified? AJR American Journal of Roentgenology, 202(4), 868–871. Scholar
  106. Marini, J. C., & Blissett, A. R. (2013). New genes in bone development: What’s new in osteogenesis imperfecta. Journal of Clinical Endocrinology & Metabolism, 98(8), 3095–3103.CrossRefGoogle Scholar
  107. Marti, B., Sirinelli, D., Maurin, L., & Carpentier, E. (2013). Wormian bones in a general paediatric population. Diagnostic and Interventional Imaging, 94(4), 428–432.CrossRefPubMedPubMedCentralGoogle Scholar
  108. Mathew, M. O., Ramamohan, N., & Bennet, G. C. (1998). Importance of bruising associated with paediatric fractures: Prospective observational study. BMJ, 317(7166), 1117–1118.CrossRefPubMedPubMedCentralGoogle Scholar
  109. Matshes, E. W., & Lew, E. O. (2010). Two-handed cardiopulmonary resuscitation can cause rib fractures in infants. American Journal of Forensic Medicine and Pathology, 31(4), 303–307.CrossRefPubMedPubMedCentralGoogle Scholar
  110. McDevitt, H., Tomlinson, C., White, M., & Ahmed, S. (2007). Changes in quantitative ultrasound in infants born at less than 32 weeks’ gestation over the first 2 years of life: Influence of clinical and biochemical changes. Calcified Tissue International, 81(4), 263–269.CrossRefPubMedPubMedCentralGoogle Scholar
  111. Mellick, L. B., & Reesor, K. (1990). Spiral tibial fractures of children: A commonly accidental spiral long bone fracture. The American Journal of Emergency Medicine, 8(3), 234–237.CrossRefPubMedPubMedCentralGoogle Scholar
  112. Mellick, L. B., Milker, L., & Egsieker, E. (1999). Childhood accidental spiral tibial (CAST) fractures. Pediatric Emergency Care, 15, 307–309.CrossRefPubMedPubMedCentralGoogle Scholar
  113. Merten, D., Radkowski, M., & Leonidas, J. C. (1983). The abused child: A radiological reappraisal. Radiology, 146(2), 377–381.CrossRefPubMedPubMedCentralGoogle Scholar
  114. Meservy, C. J., Towbin, R., McLaurin, R. L., Myers, P. A., & Ball, W. (1987). Radiographic characteristics of skull fractures resulting from child abuse. American Journal of Roentgenology, 149(1), 173–175.CrossRefPubMedPubMedCentralGoogle Scholar
  115. Misra, M., Pacaud, D., Petryk, A., Collett-Solberg, P. F., & Kappy, M. (2008). Vitamin D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics, 122(2), 398–417.CrossRefGoogle Scholar
  116. Morris, S., Cassidy, N., Stephens, M., McCormack, D., & McManus, F. (2002). Birth-associated femoral fractures: Incidence and outcome. Journal of Pediatric Orthopaedics, 22(1), 27–30.PubMedPubMedCentralGoogle Scholar
  117. Moyer-Mileur, L., Luetkemeier, M., Boomer, L., & Chan, G. M. (1995). Effect of physical activity on bone mineralization in premature infants. Journal of Pediatrics, 127(4), 620–625.CrossRefPubMedPubMedCentralGoogle Scholar
  118. Murphy, R., Kelly, D. M., Moisan, A., Thompson, N. B., Warner, W. C., Jr., Beaty, J. H., & Sawyer, J. R. (2015). Transverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures are. JBJS, 97(2), 106–111.CrossRefGoogle Scholar
  119. Nimkin, K., Spevak, M. R., & Kleinman, P. K. (1997). Fractures of the hands and feet in child abuse: Imaging and pathologic features. Radiology, 203(1), 233–236.CrossRefPubMedPubMedCentralGoogle Scholar
  120. O’Connell, A., & Donoghue, V. B. (2007). Can classic metaphyseal lesions follow uncomplicated caesarean section? Pediatric Radiology, 37(5), 488–491.CrossRefPubMedPubMedCentralGoogle Scholar
  121. O’Connor-Read, L., Teh, J., & Willett, K. (2007). Radiographic evidence to help predict the mechanism of injury of pediatric spiral fractures in nonaccidental injury. Journal of Pediatric Orthopaedics, 27(7), 754–757.CrossRefPubMedPubMedCentralGoogle Scholar
  122. Ogden, J. A. (1990). Skeletal injury in the child (2nd ed.). Philadelphia: Saunders.Google Scholar
  123. Paine, C. W., Fakeye, O., Christian, C. W., & Wood, J. N. (2016). Prevalence of abuse among young children with rib fractures: A systematic review. Pediatric Emergency Care. Advance online publication.
  124. Pandya, N. K., Baldwin, K. D., Wolfgruber, H., Drummond, D. S., & Hosalkar, H. S. (2010). Humerus fractures in the pediatric population: An algorithm to identify abuse. Journal of Pediatric Orthopaedics Part B, 19(6), 535–541.CrossRefPubMedPubMedCentralGoogle Scholar
  125. Parisi, M. T., Wiester, R. T., Done, S. L., Sugar, N. F., & Feldman, K. W. (2015). Three-dimensional computed tomography skull reconstructions as an aid to child abuse evaluations. Pediatric Emergency Care, 31(11), 779–786.CrossRefPubMedPubMedCentralGoogle Scholar
  126. Pecci, M., & Kreher, J. B. (2008). Clavicle fractures. American Family Physician, 77(1), 65.PubMedPubMedCentralGoogle Scholar
  127. Perez-Rossello, J. M., Connolly, S. A., Newton, A. W., Thomason, M., Jenny, C., Sugar, N. F., & Kleinman, P. K. (2008). Pubic ramus radiolucencies in infants: The good, the bad, and the indeterminate. American Journal of Roentgenology, 190(6), 1481–1486.CrossRefPubMedPubMedCentralGoogle Scholar
  128. Perez-Rossello, J. M., Connolly, S. A., Newton, A. W., Zou, K. H., & Kleinman, P. K. (2010). Whole-body MRI in suspected infant abuse. American Journal of Roentgenology, 195(3), 744–750.CrossRefPubMedPubMedCentralGoogle Scholar
  129. Perez-Rossello, J. M., Feldman, H. A., Kleinman, P. K., Connolly, S. A., Fair, R. A., Myers, R. M., & Gordon, C. M. (2012). Rachitic changes, demineralization, and fracture risk in healthy infants and toddlers with vitamin D deficiency. Radiology, 262(1), 234–241.CrossRefPubMedPubMedCentralGoogle Scholar
  130. Perez-Rossello, J. M., McDonald, A. G., Rosenberg, A. E., Tsai, A., & Kleinman, P. K. (2015). Absence of rickets in infants with fatal abusive head trauma and classic metaphyseal lesions. Radiology, 275(3), 810–821.CrossRefPubMedPubMedCentralGoogle Scholar
  131. Perkins, R., & Skirving, A. (1987). Callus formation and the rate of healing of femoral fractures in patients with head injuries. Bone & Joint Journal, 69(4), 521–524.Google Scholar
  132. Peters, M. L., Starling, S. P., Barnes-Eley, M. L., & Heisler, K. W. (2008). The presence of bruising associated with fractures. Archives of Pediatrics & Adolescent Medicine, 162(9), 877–881.CrossRefGoogle Scholar
  133. Pierce, M. C., Bertocci, G. E., Vogeley, E., & Moreland, M. S. (2004). Evaluating long bone fractures in children: A biomechanical approach with illustrative cases. Child Abuse & Neglect, 28(5), 505–524.CrossRefGoogle Scholar
  134. Pierce, M. C., Bertocci, G. E., Janosky, J. E., Aguel, F., Deemer, E., Moreland, M., et al. (2005). Femur fractures resulting from stair falls among children: An injury plausibility model. Pediatrics, 115(6), 1712–1722. Scholar
  135. Prosser, I., Maguire, S., Harrison, S. K., Mann, M., Sibert, J. R., & Kemp, A. M. (2005). How old is this fracture? Radiologic dating of fractures in children: A systematic review. American Journal of Roentgenology, 184(4), 1282–1286.CrossRefPubMedPubMedCentralGoogle Scholar
  136. Prosser, I., Lawson, Z., Evans, A., Harrison, S., Morris, S., Maguire, S., & Kemp, A. M. (2012). A timetable for the radiologic features of fracture healing in young children. American Journal of Roentgenology, 198(5), 1014–1020.CrossRefPubMedPubMedCentralGoogle Scholar
  137. Quigley, A. J., & Stafrace, S. (2014). Skeletal survey normal variants, artefacts and commonly misinterpreted findings not to be confused with non-accidental injury. Pediatric Radiology, 44(1), 82–93.CrossRefPubMedPubMedCentralGoogle Scholar
  138. Quinby, W. C. (1966). Fractures of the pelvis and associated injuries in children. Journal of Pediatric Surgery, 1(4), 353–364.CrossRefPubMedPubMedCentralGoogle Scholar
  139. Rauch, F., & Schoenau, E. (2002). Skeletal development in premature infants: A review of bone physiology beyond nutritional aspects. Archives of Disease in Childhood-Fetal and Neonatal Edition, 86(2), F82–F85.CrossRefPubMedPubMedCentralGoogle Scholar
  140. Ravichandiran, N., Schuh, S., Bejuk, M., Al-Harthy, N., Shouldice, M., Au, H., & Boutis, K. (2010). Delayed identification of pediatric abuse-related fractures. Pediatrics, 125(1), 60–66.CrossRefPubMedPubMedCentralGoogle Scholar
  141. Renaud, A., Aucourt, J., Weill, J., Bigot, J., Dieux, A., Devisme, L., et al. (2013). Radiographic features of osteogenesis imperfecta. Insights Imaging, 4(4), 417–429. Scholar
  142. Rivara, F. P., Parish, R. A., & Mueller, B. A. (1986). Extremity injuries in children: Predictive value of clinical findings. Pediatrics, 78(5), 803–807.PubMedPubMedCentralGoogle Scholar
  143. Rodríguez-Merchán, E. C. (2005). Pediatric fractures of the forearm. Clinical Orthopaedics and Related Research, 432, 65–72.CrossRefGoogle Scholar
  144. Ryznar, E., Rosado, N., & Flaherty, E. G. (2015). Understanding forearm fractures in young children: Abuse or not abuse? Child Abuse & Neglect, 47, 132–139.CrossRefGoogle Scholar
  145. Schilling, S., Wood, J. N., Levine, M. A., Langdon, D., & Christian, C. W. (2011). Vitamin D status in abused and nonabused children younger than 2 years old with fractures. Pediatrics, 127, 835–893.CrossRefPubMedPubMedCentralGoogle Scholar
  146. Servaes, S., Brown, S. D., Choudhary, A. K., Christian, C. W., Done, S. L., Hayes, L. L., et al. (2016). The etiology and significance of fractures in infants and young children: A critical multidisciplinary review. Pediatric Radiology, 46(5), 591–600.CrossRefPubMedPubMedCentralGoogle Scholar
  147. Shopfner, C. E. (1966). Periosteal bone growth in normal infants: A preliminary report. American Journal of Roentgenology, Radium Therapy, and Nuclear Medicine, 97(1), 154–163.CrossRefPubMedPubMedCentralGoogle Scholar
  148. Sibert, J. R., Payne, E. H., Kemp, A. M., Barber, M., Rolfe, K., Morgan, R. J., et al. (2002). The incidence of severe physical child abuse in Wales. Child Abuse & Neglect, 26(3), 267–276.CrossRefGoogle Scholar
  149. Sillence, D. (1988). Osteogenesis imperfecta nosology and genetics. Annals of the New York Academy of Sciences, 543(1), 1–16.CrossRefPubMedPubMedCentralGoogle Scholar
  150. Sillence, D., Barlow, K., Cole, W., Dietrich, S., Garber, A., Rimoin, D., et al. (1986). Osteogenesis imperfecta type III: Delineation of the phenotype with reference to genetic heterogeneity. American Journal of Medical Genetics Part A, 23(3), 821–832.CrossRefGoogle Scholar
  151. Sonik, A., Stein-Wexler, R., Rogers, K. K., Coulter, K. P., & Wootton-Gorges, S. L. (2010). Follow-up skeletal surveys for suspected non-accidental trauma: Can a more limited survey be performed without compromising diagnostic information? Child Abuse & Neglect, 34(10), 804–806.CrossRefGoogle Scholar
  152. Starling, S. P., Sirotnak, A. P., Heisler, K. W., & Barnes-Eley, M. L. (2007). Inflicted skeletal trauma: The relationship of perpetrators to their victims. Child Abuse & Neglect, 31(9), 993–999.CrossRefGoogle Scholar
  153. Stokes, N., & Cremin, B. (1974). The skull vault in neonates and infants. Journal of Medical Imaging and Radiation Oncology, 18(3), 275–282.Google Scholar
  154. Supakul, N., Hicks, R. A., Caltoum, C. B., & Karmazyn, B. (2015). Distal humeral epiphyseal separation in young children: An often-missed fracture—Radiographic signs and ultrasound confirmatory diagnosis. American Journal of Roentgenology, 204(2), W192–W198.CrossRefPubMedPubMedCentralGoogle Scholar
  155. Tharakan, S. J., Lee, R. J., White, A. M., & Lawrence, J. T. R. (2016). Distal humeral epiphyseal separation in a newborn. Orthopedics, 39(4), e764–e767.CrossRefPubMedPubMedCentralGoogle Scholar
  156. Tran, B., Silvera, M., Newton, A., & Kleinman, P. K. (2007). Inflicted T12 fracture-dislocation: CT/MRI correlation and mechanistic implications. Pediatric Radiology, 37(11), 1171–1173.CrossRefPubMedPubMedCentralGoogle Scholar
  157. Uddenfeldt Wort, U., Nordmark, E., Wagner, P., Düppe, H., & Westbom, L. (2013). Fractures in children with cerebral palsy: A total population study. Developmental Medicine & Child Neurology, 55(9), 821–826.CrossRefGoogle Scholar
  158. Valencia, J., Leyva, F., & Gomez-Bajo, G. J. (2005). Pediatric hand trauma. Clinical Orthopaedics and Related Research, 432, 77–86.CrossRefGoogle Scholar
  159. Van Dijk, F. S., Dalgleish, R., Malfait, F., et al. (2013). Clinical utility gene card for: Osteogenesis imperfecta. European Journal of Human Genetics, 21(6).
  160. van Rijn, R. R., Bilo, R. A., & Robben, S. G. (2009). Birth-related mid-posterior rib fractures in neonates: A report of three cases (and a possible fourth case) and a review of the literature. Pediatric Radiology, 39(1), 30–34.CrossRefPubMedPubMedCentralGoogle Scholar
  161. Walters, M. M., Forbes, P. W., Buonomo, C., & Kleinman, P. K. (2014). Healing patterns of clavicular birth injuries as a guide to fracture dating in cases of possible infant abuse. Pediatric Radiology, 44(10), 1224–1229.CrossRefPubMedPubMedCentralGoogle Scholar
  162. Warner, C., Maguire, S., Trefan, L., Miller, A., Weinman, J., & Fadell, M. (2017). A study of radiological features of healing in long bone fractures among infants less than a year. Skeletal Radiology, 46(3), 333–341.CrossRefPubMedPubMedCentralGoogle Scholar
  163. Weber, W. (1984). Experimental studies of skull fractures in infants. Zeitschrift fur Rechtsmedizin/Journal of Legal Medicine, 92(2), 87–94.CrossRefGoogle Scholar
  164. Weber, W. (1985). Biomechanical fragility of the infant skull. Zeitschrift fur Rechtsmedizin/Journal of Legal Medicine, 94(2), 93–101.Google Scholar
  165. Weber, W. (1987). Predilection sites of infantile skull fractures following blunt force. Zeitschrift fur Rechtsmedizin/Journal of Legal Medicine, 98(2), 81–93.Google Scholar
  166. Wharton, B., & Bishop, N. (2003). Rickets. Lancet, 362(9393), 1389–1400.CrossRefPubMedPubMedCentralGoogle Scholar
  167. Wood, J. N., Fakeye, O., Mondestin, V., Rubin, D. M., Localio, R., & Feudtner, C. (2014a). Prevalence of abuse among young children with femur fractures: A systematic review. BMC Pediatrics, 14(1), 169.CrossRefPubMedPubMedCentralGoogle Scholar
  168. Wood, J. N., Fakeye, O., Feudtner, C., Mondestin, V., Localio, R., & Rubin, D. M. (2014b). Development of guidelines for skeletal survey in young children with fractures. Pediatrics, 134(1), 45–53. Scholar
  169. Wootton-Gorges, S. L., Stein-Wexler, R., Walton, J. W., Rosas, A. J., Coulter, K. P., & Rogers, K. K. (2008). Comparison of computed tomography and chest radiography in the detection of rib fractures in abused infants. Child Abuse & Neglect, 32(6), 659–663.CrossRefGoogle Scholar
  170. Worlock, P., Stower, M., & Barbor, P. (1986). Patterns of fractures in accidental and non-accidental injury in children: A comparative study. British Medical Journal (Clinical Research Edition), 293(6539), 100–102.CrossRefGoogle Scholar
  171. Zapala, M. A., Tsai, A., & Kleinman, P. K. (2016). Growth recovery lines are more common in infants at high vs. low risk for abuse. Pediatric Radiology, 46(9), 1275–1281.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Baylor College of MedicineHoustonUSA
  2. 2.Texas Children’s HospitalHoustonUSA
  3. 3.University of MinnesotaMinneapolisUSA
  4. 4.Child Abuse PediatricsUniversity of Minnesota Masonic Children’s HospitalMinneapolisUSA

Personalised recommendations