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Textbook/Clinical imaging and interpretation/Paediatric fracture imaging and non-accidental injury
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Paediatric fracture imaging and non-accidental injury

Interpret paediatric fracture imaging with growth-plate awareness, recognise patterns and histories that raise safeguarding concern, and use a specialist protocol for suspected physical abuse.

26 min full readUK scopeSources checked 13 Sept 2026Clinical review pending
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Treat injury and protect the child together

Airway, breathing, circulation, intracranial injury, sepsis, neurovascular compromise and severe pain require immediate care while safeguarding actions proceed in parallel.

Action: Stabilise the child, document objective findings and exact history, involve senior paediatrics and the safeguarding lead, and prevent discharge until medical and safety plans have named ownership.

Open the sections you need. The overview is shown first.
01Purpose and principlesWhat the assessment is for and the core concepts behind it.

Children are not small adults on radiographs. The physis, unossified epiphysis and changing secondary ossification centres alter what can be seen and what constitutes alignment. Mechanism must be plausible for developmental ability. Subtle buckle, greenstick and plastic-deformation injuries reflect flexible bone, while physeal injuries can be invisible when separation occurs through cartilage.

Safeguarding concern arises from the whole presentation rather than a single supposedly diagnostic fracture. Age, mobility, mechanism, delay, changing accounts, additional injuries and medical causes of fragility all matter. Radiologists date fractures only within broad and overlapping ranges; apparent different healing stages can support concern but should not be converted into precise injury dates. The reporting language should be descriptive and balanced.

A formal skeletal survey is a standardised series designed to detect occult fractures throughout the skeleton. It requires trained staff, appropriate immobilisation without compromising care, quality assurance and paediatric-radiologist interpretation. Follow-up views can reveal healing fractures that were initially occult. Head, spine, abdominal or other imaging is selected by age, findings and the specialist safeguarding protocol; one negative component does not exclude abuse.

Key points

  • Check identity, side, mechanism, developmental ability, exact tenderness and neurovascular status before interpreting paediatric trauma images.
  • Obtain well-collimated orthogonal radiographs of the correct region, recognising normal ossification centres, physes and age-dependent alignment.
  • A radiographically occult Salter-Harris I injury remains possible when focal physeal tenderness persists; protect the limb and arrange review. Separately, suspected physical abuse requires a formal RCR/SCoR skeletal survey in children under two, while older children are assessed case by case.
  • When physical abuse is suspected, urgent medical treatment and a senior paediatric safeguarding assessment proceed together; use objective, contemporaneous documentation.
  • Do not improvise a few regional films as a skeletal survey: use the current RCR/SCoR paediatric protocol, trained radiographers and paediatric-radiologist reporting.
  • For children under two in the RCR suspected-physical-abuse pathway, the skeletal survey is commonly the initial skeletal examination and protocol follow-up views are obtained 11–14 days later.
02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.
Buckle fracture

Cortical compression produces a subtle bulge without complete cortical disruption and is common in the paediatric metaphysis.

Greenstick injury

One cortex fails while the opposite side bends, so angulation and plastic deformation may be more conspicuous than a fracture line.

Physeal injury

Growth-plate widening, epiphyseal displacement or a metaphyseal fragment may be visible, while type I separation can remain radiographically occult.

Metaphyseal lesionRed flag

A corner or bucket-handle appearance in an infant requires expert safeguarding interpretation and correlation with projection, disease and the complete survey.

Rib fracturesRed flag

Posterior and multiple rib fractures, especially in a young infant, raise concern and may become clearer on protocol follow-up imaging.

Healing response

Periosteal new bone and callus indicate healing but cannot assign an exact injury date; disease, stability and age affect appearances.

Red flags requiring action

  • A fracture in a non-mobile child, an absent or implausible explanation, changing history or mechanism inconsistent with developmental ability requires safeguarding assessment.
  • Multiple fractures, different healing stages, rib fractures or classic metaphyseal lesions raise concern but must be interpreted by paediatric radiology in the full clinical context.
  • Head injury, apnoea, seizure, altered consciousness, retinal or neurological findings may coexist with skeletal injury and need urgent age-specific neuroimaging.
  • Normal initial radiographs do not exclude physeal injury or physical abuse; a negative isolated film must not close a clinically indicated specialist pathway.
03Method and interpretationA systematic approach to the test and its findings.
Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

  1. 01
    Regional radiographsFirst step
    Why
    Assess the clinically injured bone with adequate orthogonal views and inclusion of relevant adjacent joints.
    Interpretation and limitations
    Normal developmental anatomy and cartilage can obscure injury; correlate the film precisely with focal tenderness and function.
  2. 02
    Formal skeletal survey
    Why
    Detect occult fractures across the skeleton when suspected physical abuse meets the paediatric safeguarding protocol.
    Interpretation and limitations
    This is a prescribed series, not a single image; quality, completeness and specialist reporting determine its value.
  3. 03
    Follow-up skeletal survey
    Why
    Demonstrate healing and clarify equivocal lesions after the initial formal survey.
    Interpretation and limitations
    RCR audit standards specify 11–14 days and no later than 28 days; the protocol defines which repeat views are required.
  4. 04
    Computed tomography
    Why
    Assess acute head injury and selected complex bony anatomy rapidly when specialist protocol indicates.
    Interpretation and limitations
    CT uses ionising radiation and is not a substitute for the skeletal survey or MRI follow-up where those are required.
  5. 05
    Magnetic resonance imaging
    Why
    Evaluate brain, spine, marrow, cartilage or an occult regional injury without ionising radiation.
    Interpretation and limitations
    Sedation, motion and timing affect delivery; MRI complements rather than automatically replaces protocol radiography or acute CT.
04Clinical next stepsHow the result changes management or prompts escalation.
01Paediatric traumaRead with growth in mindFirst stepA child presents with focal pain or dysfunction after a plausible acute injury.
  1. 1Establish developmental ability, mechanism, exact site, skin condition and distal neurovascular findings.
  2. 2Obtain adequate orthogonal regional radiographs and identify the expected physes and ossification centres.
  3. 3Describe fracture morphology, displacement, articular or physeal involvement and any concerning associated injury.
  4. 4Protect a clinically suspected occult injury and arrange defined review when imaging and examination remain discordant.
02Safeguarding pathwayUse the formal imaging protocolHistory, development, examination or imaging raises suspected physical abuse.
  1. 1Treat urgent injuries and involve senior paediatrics and the safeguarding lead without interviewing repeatedly or delaying care.
  2. 2Record who gave the history, their exact words, timing, developmental context and all objective positive and negative findings.
  3. 3Request the age- and finding-specific RCR/SCoR imaging pathway rather than selecting isolated radiographs independently.
  4. 4Ensure specialist reporting, multidisciplinary review, protocol follow-up and an explicit medical and discharge safety plan.
03Survey follow-upComplete and reconcile imagingAn initial skeletal survey has been performed for suspected physical abuse.
  1. 1Check survey completeness and image quality against the current protocol before accepting a negative examination.
  2. 2Arrange follow-up views at 11–14 days, with any variation directed by the specialist paediatric radiology team.
  3. 3Reconcile new healing lesions, equivocal findings, laboratory results and plausible medical mimics in the multidisciplinary review.
  4. 4Communicate the integrated conclusion and ensure each clinical, evidential and safeguarding action has a named owner.
05Risks, monitoring and follow-upComplications, safety checks and further assessment.
  • Repeat neurovascular examination after splintage or reduction and document any change immediately.
  • For high-risk physeal injury, monitor alignment, limb length and growth over the period advised by paediatric orthopaedics.
  • Track formal skeletal-survey completion, specialist report, follow-up appointment and multidisciplinary safeguarding discussion.
  • Record discrepancies, additional injuries and revisions to the history contemporaneously using neutral language.
  • Do not discharge until analgesia, fracture care, imaging follow-up and the multi-agency safety plan are explicit.
06Special situationsVariants, exceptions and circumstances that change the usual approach.

Ossification follows age

Apparent fragments may be normal centres, while important cartilaginous injury may be invisible until secondary signs appear.

Fracture type is contextual

No single fracture proves abuse; specificity depends on age, mobility, mechanism, location, multiplicity and expert interpretation.

Dating is imprecise

Callus and periosteal response provide broad healing information but cannot reliably identify a precise day of injury.

Survey means protocol

Standard projections and quality checks improve occult-fracture detection and reduce both missed injury and false accusation.

Follow-up adds sensitivity

Healing can make initially subtle rib and metaphyseal injuries visible, which is why the second survey is a planned diagnostic component.

Safeguarding runs beside resuscitation

Protective processes must not delay treatment of head injury, sepsis, compromised circulation or other immediate threats.

07Common pitfallsFrequent interpretation and management errors.
  1. 01

    Mistaking a normal ossification centre for a fracture fragment.

  2. 02

    Excluding a physeal injury because no line is visible.

  3. 03

    Treating one fracture pattern as proof of abuse without clinical context.

  4. 04

    Ordering isolated films instead of the formal suspected-abuse skeletal survey.

  5. 05

    Discharging before follow-up imaging and safeguarding ownership are secured.

Practice

Two practice questions

Question 1 of 20 correct
Clinical imaging and interpretationOriginal SBA

Occult physeal injury

A nine-year-old has focal tenderness directly over the distal fibular physis after a twisting injury, but adequate ankle radiographs show no fracture. What is the safest interpretation?

Sources and review status6 sources · checked 13 Sept 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 13 Sept 2026; clinical approval remains outstanding.

  • NICE NG38 non-complex fractures recommendationsCurrent live recommendations checked 13 September 2026; paediatric fracture assessment and imaging context; England national guidance.
  • NICE CG89 child maltreatment recommendationsPublished July 2009 with 2024 surveillance; live recommendations read 13 September 2026; under-18 alerting features and suspicion threshold, not an imaging protocol.
  • RCR/SCoR suspected physical abuse imaging guidanceRevised first edition November 2018, still current on the official RCR page checked 13 September 2026; forensic imaging of children with suspected physical abuse.
  • RCR skeletal survey quality standardCurrent official audit standard checked 13 September 2026; children under two, formal survey quality and 11–14-day follow-up, no later than 28 days.
  • BOAST paediatric forearm fractureCurrent UK professional standard checked 13 September 2026; early assessment, neurovascular documentation and follow-up for paediatric forearm fractures.
  • RCH distal tibia and fibula physeal fracture guidelineCurrent Royal Children’s Hospital Melbourne clinical practice guideline checked 13 September 2026; paediatric distal tibial/fibular physeal injury. A type I injury may be radiographically occult and diagnosed by localised distal-fibular tenderness; isolated undisplaced distal-fibular physeal injury is immobilised, kept non-weight bearing and reviewed in fracture clinic in 7–10 days with repeat radiography. Australian institutional guidance, not UK national policy.
Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom