Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Paediatric fracture imaging and non-accidental injury
Essential points for quick revision.
2 min synopsisUK 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.
Synopsis
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.
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.
Key red flags
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.
Metaphyseal lesion
A corner or bucket-handle appearance in an infant requires expert safeguarding interpretation and correlation with projection, disease and the complete survey.
Rib fractures
Posterior and multiple rib fractures, especially in a young infant, raise concern and may become clearer on protocol follow-up imaging.
Investigation priorities
01
Regional radiographsFirst step
Assess the clinically injured bone with adequate orthogonal views and inclusion of relevant adjacent joints.
Management branches
Paediatric traumaRead with growth in mind
A child presents with focal pain or dysfunction after a plausible acute injury.
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 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.