Skip to textbook content
Doctor’s PassportTextbook
TopicsAll topics

Loading topic navigation…

Textbook navigation
TopicsAll topics

Loading topic navigation…
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.

Non-accidental injury fracture patterns

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
!
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.

Synopsis

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.

  • 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.
  • 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.

Key red flags

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.

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.

Immediate danger

Altered consciousness, seizures, shock, respiratory compromise or abdominal signs require resuscitation and urgent multisystem imaging.

Investigation priorities

01
First-line full clinical assessmentFirst stepFirst line

Record a chronological verbatim history, developmental ability, growth and complete skin, oral, neurological, abdominal and musculoskeletal examination.

Management branches

Immediate careTreat injury and secure safety

A child has a fracture plus possible physical abuse or associated internal injury.

  1. Use ABCDE, analgesia, immobilisation and urgent head, chest, abdominal, orthopaedic or neurosurgical treatment according to findings.
  2. Notify the senior paediatrician and safeguarding team, maintain observation and prevent discharge until a safe plan is agreed.
  3. Record contemporaneous facts, exact words, times and all contacts while preserving forensic and radiological evidence.

Key medicines

ParacetamolUse 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.
Morphine for severe acute painUse 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.
Open full textbook →Answer 2 questions
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.
  • RCR radiological investigation of suspected physical abuseUK technical skeletal-survey, follow-up and age-appropriate additional imaging standards.
  • RCR skeletal survey quality standardInitial reporting timing and follow-up imaging at 11 to 14 days, no later than 28 days.
  • RCPCH fracture systematic reviewEvidence on age, mobility, rib, metaphyseal, humeral, femoral and multiple fracture associations and limitations of dating.
  • GMC protecting children and young peopleProfessional duties for child-centred communication, confidentiality, information sharing and safeguarding action.
  • 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 ·

Content changes
Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom