Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Non-accidental injury fracture patterns
Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Injured child with immediate safeguarding risk
A young child has a fracture with an incompatible account and may also have head, chest or abdominal injury or face unsafe discharge.
Action: Stabilise ABCDE, give analgesia, immobilise and treat neurovascular or internal injury, then contact the senior paediatrician and safeguarding team immediately. Preserve objective documentation, arrange protocol imaging and laboratory assessment, notify statutory agencies through the local pathway and maintain a supervised safe location pending a disposition decision.
Overview
Recognise fractures and histories that require assessment for physical abuse, stabilise injury and immediate safety, use the UK child-protection imaging pathway correctly and reach a multidisciplinary conclusion without treating any single fracture as pathognomonic.
A fracture may be accidental, inflicted, related to birth or medical treatment, or caused or facilitated by bone disease. The clinician's task is not to infer intent from an X-ray in isolation but to identify concern, treat injury, protect the child and assemble reliable evidence for multidisciplinary decision-making. Use neutral language such as 'the explanation is not compatible with the child's observed developmental ability' and distinguish reported history, observed fact, radiological opinion and clinical inference.
Begin with the child rather than the fracture. Stabilise life-threatening injury using ABCDE, provide analgesia and assess neurovascular status. Examine for head, spinal, thoracic, abdominal and oral injury because fractures may be one component of multisystem trauma. A normal initial appearance does not exclude intracranial or visceral injury in an infant. Escalate immediately to the senior paediatrician and local safeguarding team and ensure the child is not discharged into an unresolved unsafe situation.
Practice
Two practice questions
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Question 1 of 2
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Paediatrics and child healthOriginal SBA
Fracture in a non-mobile infant
A 7-month-old who cannot crawl has a femoral fracture. The account changes and does not plausibly explain the injury. The infant is clinically stable after analgesia and splinting. What is the best next action?
Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE CG89 child maltreatmentWhen fracture, history, development and associated injuries should raise suspicion of physical abuse.
RCPCH fracture systematic reviewEvidence on age, mobility, rib, metaphyseal, humeral, femoral and multiple fracture associations and limitations of dating.
BNF for ChildrenCurrent child paracetamol and morphine doses, routes, contraindications and monitoring requirements.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·
Take a careful chronological history separately from examination where possible. Record exactly who was present, when the child was last well, when pain or loss of use was noticed, when help was sought and every account of the mechanism. Ask what the child can independently do: rolling, crawling, cruising, walking, climbing and falling from known heights. Review previous injuries, hospital contacts, birth trauma, resuscitation, prematurity, nutrition, vitamin supplementation, chronic illness, medicines and family history of fractures, hearing loss, blue sclerae or known bone disease.
Concern rises when the explanation is absent, changes materially, is implausible for the child's developmental stage or does not account for injury severity. Delay in presentation, multiple injuries, a non-mobile infant with any unexplained fracture or repeated attendance also matters. However, family distress, uncertain timing or an imperfect account alone does not prove abuse. Communication barriers, neurodevelopmental differences and fragmented care records should be addressed fairly while safety remains paramount.
Certain patterns have stronger associations. Classic metaphyseal lesions arise from shearing at the growing metaphysis and are uncommon after ordinary handling. Rib fractures in a young child without major trauma, birth injury or underlying bone disease have high predictive value, and posterior or multiple adjacent rib fractures are especially concerning. Multiple fractures, particularly with different healing appearances, require explanation. Scapular, sternal and spinous-process fractures are unusual in routine childhood accidents and prompt scrutiny of mechanism and associated injury.
Common fractures can still be inflicted and concerning fractures can have alternatives. Linear skull fractures occur in both accidental and abusive injury. Femoral shaft and spiral fractures are not intrinsically diagnostic; a supracondylar humeral fracture in a mobile child after a witnessed fall differs greatly from a humeral fracture in a non-mobile infant. Fracture dating is imprecise: radiological healing represents a continuum and supports broad estimates in weeks rather than an exact day.
Perform a documented top-to-toe examination with a chaperone according to local policy. Record growth parameters, head circumference in young children, skin lesions, patterned bruising, burns, scalp swelling, oral or frenulum injury, chest or abdominal tenderness, genital findings when clinically indicated, limb swelling, bony tenderness and neurological state. Use body maps and approved clinical photography processes. Do not repeatedly manipulate painful limbs merely to demonstrate an abnormality.
For a child under 2 years undergoing clinical investigation for suspected physical abuse, request a complete skeletal survey through the RCR and Society of Radiographers technical protocol. This is a series of high-quality, coned images, not a 'babygram'. It should be acquired and reported promptly, normally within 24 hours and certainly no later than 72 hours from request. A trained paediatric radiologist or appropriately experienced radiologist reviews the images, ideally with double reporting according to the pathway.
Follow-up skeletal imaging at 11 to 14 days, and no later than 28 days, is a planned part of the protocol after an initial survey. Healing can make rib or metaphyseal injuries visible and resolve normal variants or equivocal findings. Children older than 2 years require individually selected imaging based on history, examination and specialist discussion rather than automatic application of an infant protocol. Additional head CT or MRI, abdominal imaging and ophthalmological examination follow current age- and presentation-specific guidance.
Medical investigation should test plausible alternatives without creating a false dichotomy between abuse and disease. Depending on findings, assess full blood count and film, coagulation, calcium, phosphate, alkaline phosphatase, parathyroid hormone, vitamin D, renal and liver indices. Seek metabolic bone or genetics advice for fractures with osteopenia, abnormal mineralisation, growth failure, characteristic sclerae or teeth, marked ligamentous laxity or a strong family history. Osteogenesis imperfecta and rickets can coexist with safeguarding risk; finding vulnerability does not explain every mechanism automatically.
Information sharing must be proportionate, relevant and timely. Explain concerns and planned referral to parents or carers unless doing so would increase risk, prejudice a police investigation or otherwise conflict with the child's interests. Consent should be sought for examination and imaging where practicable, but parental refusal does not end a necessary protection assessment: obtain senior safeguarding, radiology and legal advice and use the applicable statutory or court-authorised route. Law and operational terminology differ across England, Wales, Scotland and Northern Ireland, so follow the child's local pathway.
The multidisciplinary conclusion integrates paediatrics, paediatric radiology, orthopaedics, social care or social work, police where required and other specialists. Provide clear treatment for every injury, safe placement, follow-up skeletal survey ownership and written handover. Consider whether siblings or other children may be at risk through the formal safeguarding process; do not independently examine or image contacts without the appropriate clinical and legal pathway. Continue respectful, trauma-informed care for child and family while maintaining professional curiosity.
Key points
Use suspected physical abuse in clinical reasoning: the older phrase non-accidental injury can imply a conclusion before the history, examination, imaging and multidisciplinary assessment are complete.
No fracture is diagnostic of abuse by itself. Interpret location, morphology, number and healing together with age, developmental ability, bone health, proposed mechanism and associated injuries.
A fracture in a non-mobile infant, an absent or changing explanation, delay in seeking help, or a mechanism incompatible with development requires prompt safeguarding assessment.
Fracture patterns of high concern include classic metaphyseal lesions, rib fractures without major trauma, birth injury or bone disease, and multiple fractures at different stages of healing; uncommon scapular, sternal or spinous-process fractures also need careful explanation.
A spiral fracture is not automatically inflicted, and a skull or femoral fracture shape alone cannot determine intent. Developmental stage and the complete clinical context carry more meaning than a memorable label.
Treat airway, breathing, circulation, pain, head injury, abdominal injury and neurovascular compromise first while activating senior paediatric and safeguarding support; emergency care must never wait for the social history to be completed.
Aetiology
01
Inflicted force
Compression, traction, twisting, impact or shaking can exceed immature bone tolerance and may produce fractures with other soft-tissue injury.
02
Unintentional trauma
Falls, sport, transport injury and developmentally plausible accidents remain common and can cause simple or complex fracture patterns.
03
Bone fragility
Rickets, osteogenesis imperfecta, osteopenia of prematurity and chronic disease can lower fracture threshold without excluding coincident harm.
04
Birth or healthcare injury
Difficult delivery, resuscitation, surgery and vascular or intraosseous procedures can occasionally produce injuries requiring documented temporal correlation.
Pathophysiology
1
Shear at the metaphysis
Traction and rotational shear can disrupt fragile primary spongiosa near the physis, producing a classic metaphyseal lesion.
2
Thoracic compression
Anterior-posterior chest compression can lever ribs against transverse processes, contributing to posterior and multiple rib fractures.
3
Healing continuum
Periosteal reaction, callus and remodelling develop gradually with substantial overlap, limiting fracture dating to broad time windows.
4
Multisystem force transmission
The same event may injure skull, brain, viscera, skin and skeleton, so isolated musculoskeletal assessment can miss life-threatening harm.
Clinical features and red flags
Developmental mismatch
The proposed mechanism requires motor skills the child has not attained or cannot plausibly generate the observed injury.
High-concern fracture pattern
Classic metaphyseal, unexplained rib or unusual scapular, sternal or spinous-process fractures require specialist safeguarding assessment.
Multiple healing stages
Fractures with different healing appearances suggest events over time but cannot be assigned exact dates from radiographs.
Associated injury
Patterned bruising, oral trauma, intracranial findings or abdominal injury strengthens concern and may require emergency treatment.
Bone-disease phenotype
Growth failure, bowing, blue sclerae, abnormal teeth or strong fracture family history prompts parallel metabolic or genetic assessment.
Immediate dangerRed flag
Altered consciousness, seizures, shock, respiratory compromise or abdominal signs require resuscitation and urgent multisystem imaging.
Red flags requiring action
Any unexplained fracture in a non-mobile infant requires urgent safeguarding assessment.
An absent, changing or developmentally incompatible account increases concern but must be documented objectively.
Classic metaphyseal lesions, unexplained rib fractures or multiple fractures at different healing stages are high-concern findings.
Investigations
01First-line full clinical assessmentFirst stepFirst line
Why
Record a chronological verbatim history, developmental ability, growth and complete skin, oral, neurological, abdominal and musculoskeletal examination.
Interpretation and limitations
Compatibility between mechanism, development and every injury matters; one plausible injury does not automatically explain the remainder.
02Gold-standard protocol skeletal survey
Why
Use the complete RCR and Society of Radiographers series in children under 2 undergoing investigation for suspected physical abuse.
Interpretation and limitations
Multiple coned views identify occult and subtle injury; a single whole-body image is technically and diagnostically inadequate.
03Mandatory planned follow-up survey
Why
Repeat the specified views 11 to 14 days after the first survey, and no later than 28 days, through the same safeguarding pathway.
Interpretation and limitations
Healing may reveal rib or metaphyseal fractures and distinguish genuine injury from equivocal anatomy or normal variants.
04Age-specific head imaging
Why
Use current RCR and local protocols for CT or MRI when age, skull fracture, neurological signs or abuse concern creates intracranial risk.
Interpretation and limitations
Normal consciousness does not exclude infant intracranial injury; MRI can further define brain, spine and injury timing patterns.
Differential diagnosis
01
Developmentally plausible accident
A consistent witnessed mechanism matching mobility, injury biomechanics and associated findings may support an unintentional explanation.
02
Osteogenesis imperfecta
Recurrent fractures, family history, blue or grey sclerae, dentinogenesis imperfecta, hearing problems or wormian bones may prompt genetics assessment.
03
Rickets or metabolic bone disease
Growth failure, bowing, widened wrists, dietary risk and abnormal calcium, phosphate, alkaline phosphatase or parathyroid hormone suggest impaired mineralisation.
04
Birth and resuscitation injury
Clavicular, humeral or rib injury may relate to documented difficult delivery or resuscitation when timing and morphology are compatible.
05
Normal radiological variant
Metaphyseal irregularity, accessory ossification and physiological periosteal reaction require experienced paediatric radiology interpretation to avoid misclassification.
Management
01Immediate careTreat injury and secure safetyFirst stepA child has a fracture plus possible physical abuse or associated internal injury.+
1Use ABCDE, analgesia, immobilisation and urgent head, chest, abdominal, orthopaedic or neurosurgical treatment according to findings.
2Notify the senior paediatrician and safeguarding team, maintain observation and prevent discharge until a safe plan is agreed.
3Record contemporaneous facts, exact words, times and all contacts while preserving forensic and radiological evidence.
02Child-protection assessmentBuild a multidisciplinary accountHistory, development, fracture pattern or associated injury creates safeguarding concern.+
1Take a full medical, developmental, social and family history and examine top to toe using body maps and approved photography where appropriate.
2
Complications
01
Recurrent or escalating harm
Missed physical abuse can expose the child and other children to further fracture, brain injury, visceral injury or death.
02
Occult head or visceral injury
Focusing only on an obvious limb fracture can miss intracranial bleeding, retinal injury or abdominal organ trauma.
03
Growth and functional impairment
Physeal injury, malunion, nerve injury and untreated pain can cause deformity, limb-length difference and chronic disability.
04
Diagnostic and relational harm
Premature accusation, poor documentation or unnecessary testing can distress families and weaken fair, evidence-based safeguarding decisions.
05
Lost follow-up evidence
Failure to arrange the timed follow-up skeletal survey can miss healing occult fractures and leave initial equivocal findings unresolved.
Monitoring and follow-up
Repeat neurological observations, pain, perfusion and abdominal assessment because occult head or visceral injury can evolve.
Check splints, casts and neurovascular status and arrange definitive orthopaedic management for every identified fracture.
Maintain an outstanding-results list for skeletal survey, radiology second opinion, laboratory tests and specialist consultations.
Confirm the follow-up skeletal survey date, transport, legal consent route and named clinician before any discharge or transfer.
Document every material change in the account without confrontational repeated interviewing that could contaminate evidence.
Review nutrition, vitamin supplementation, growth and biochemical abnormalities and ensure bone-health referrals are completed.
Use a written multi-agency safety plan and verify the child's placement and contact arrangements at handover.
Consider risk to siblings or other children only through the formal safeguarding process, with appropriate clinical and legal authority.
Provide trauma-informed communication and emotional support while preserving professional boundaries and uncertainty.
Special situations
Context outranks morphology
The same fracture has different significance in a non-mobile infant and a running child after a witnessed fall.
A babygram is inadequate
Child-protection skeletal imaging requires multiple coned projections, expert acquisition and review to find subtle occult injury.
Follow-up finds hidden injury
Callus appearing after 11 to 14 days can reveal fractures invisible initially and clarify an uncertain metaphyseal finding.
Dating remains broad
Bone healing overlaps substantially, so radiology supports ranges measured in weeks rather than a precise injury day.
Disease and harm can coexist
A fragility disorder changes fracture threshold but does not remove the need to assess whether the proposed event occurred.
Neutral words preserve evidence
Separating exact history, observed findings and professional opinion supports both child safety and fair multidisciplinary decisions.
Common pitfalls
01
Calling a spiral fracture diagnostic of abuse.
02
Ignoring developmental ability when judging a proposed mechanism.
03
Focusing on the limb and missing brain or abdominal injury.
04
Ordering a single whole-body radiograph instead of the protocol skeletal survey.
05
Failing to book and own the 11-to-14-day follow-up survey.
06
Assigning an exact date to a fracture from healing appearance.
07
Treating normal bone blood tests as proof that abuse occurred.
08
Treating a fragility diagnosis as proof that every injury was spontaneous.
09
Accusatory documentation or repeated leading questions.
10
Discharging before statutory agencies and the clinical team agree a safe plan.
When physical abuse is suspected in a child under 2 years, the UK radiology pathway generally requires a complete initial skeletal survey using specified views, acquired and interpreted by trained staff rather than a single whole-body image.
Arrange the protocol follow-up skeletal survey at 11 to 14 days after the initial survey, and no later than 28 days, because healing can reveal occult injuries and clarify uncertain findings.
Use age- and presentation-specific head imaging, ophthalmology and abdominal investigation when abusive head trauma or internal injury is possible; the skeletal survey does not replace these assessments.
Document the account verbatim, who provided it, times, developmental skills, all examination findings and clinical reasoning. Share relevant information through the applicable UK national and local safeguarding route when needed to protect the child.
Scapular, sternal or spinous-process fractures are unusual and require a mechanism and associated-injury review.
Patterned bruising, oral injury, seizures, altered consciousness, vomiting or apnoea may indicate associated abusive head trauma.
Abdominal distension, tenderness, anaemia, shock or elevated transaminases can signal occult visceral injury.
Delay in seeking care, repeated injury presentations or previous unexplained findings increases cumulative concern.
Parental refusal of indicated assessment requires senior safeguarding and legal advice, not automatic discharge.
05Directed abdominal injury assessment
Why
Check serial examination, full blood count, liver enzymes, pancreatic markers, urinalysis and CT or ultrasound when internal injury is possible.
Interpretation and limitations
Unexpected anaemia, transaminase elevation, haematuria or tenderness requires urgent paediatric surgical and radiological discussion.
06Bone-health laboratory profile
Why
Measure calcium, phosphate, alkaline phosphatase, parathyroid hormone, vitamin D, renal and liver indices according to the fracture pathway.
Interpretation and limitations
Use paediatric reference ranges and morphology; biochemical vulnerability does not by itself establish the mechanism of every fracture.
07Haematology and coagulation tests
Why
Obtain full blood count and film and directed coagulation studies when bruising, bleeding or systemic disease is present.
Interpretation and limitations
A bleeding disorder may explain bruising but does not cause fractures; abnormalities need specialist interpretation alongside injury findings.
08Specialist radiology review
Why
Ensure paediatric-experienced reporting, appropriate double review and correlation with previous imaging and clinical chronology.
Interpretation and limitations
Expert review reduces missed occult injury and misdiagnosis of normal variants, healing stage and metabolic bone disease.
Share relevant information with social care or social work and police through the applicable national and local statutory process.
3Integrate paediatric, orthopaedic and paediatric-radiology opinions and investigate plausible bone disease in parallel without delaying protection.
03Imaging sequenceComplete both survey stagesA child under 2 is undergoing clinical investigation for suspected physical abuse.+
1Request the complete initial RCR skeletal survey with trained acquisition and prompt expert reporting, not a babygram.
2Add head, spine, abdominal or other imaging according to age, signs and the current specialist protocol.
3Book and name ownership for follow-up skeletal imaging at 11 to 14 days, ensuring results return to the multidisciplinary team.
04Discharge and follow-upClose every safety and clinical loopImmediate treatment and initial safeguarding investigations are complete.+
1Agree a written safe-placement and contact plan with the statutory safeguarding team and explain it to carers when safe to do so.
2Provide fracture care, pain control and orthopaedic review while maintaining follow-up survey, head injury and bone-health appointments.
3Communicate the reasoned findings and uncertainty to primary care and receiving services, with a named professional responsible for outstanding results.
Key medicines and prescribing safety2 treatments · regimens, roles and cautions+
Provides baseline analgesia while fractures and associated injuries are examined, imaged, immobilised and treated.
Paracetamol
Use the current BNFC age- or weight-specific oral or intravenous dose, formulation, interval and maximum according to clinical status.
Record pre-hospital doses, avoid duplicate products, adjust for hepatic risk and do not let sedation or analgesia impede necessary neurological observation without a plan.
Treats severe fracture or multisystem injury pain humanely while definitive stabilisation and imaging are arranged.
Morphine for severe acute pain
Use the current local paediatric emergency and BNFC weight-based route-specific dose with titration, monitoring and naloxone availability; involve senior support for infants or instability.
Monitor respiratory rate, sedation, oxygenation and haemodynamics, reduce for organ dysfunction and never withhold necessary analgesia solely because neurological assessment is ongoing.