It is important to note that fractures in these regions may also occur accidentally, especially in the ambulatory child. Therefore, an understanding of childhood developmental expectations, mechanisms of injury, and fracture patterns is vital.

Metaphyseal corner fractures, often called “bucket handle fractures,” imply a forceful shaking, pulling, or twisting injury to the child. They cause a periosteal elevation of the metaphysis. While significant force is needed to produce these fractures, the child may not have obvious symptoms unless the injury is severe.¹⁶

Fractures involving the hands and feet should also raise suspicion, especially in nonambulatory patients. Buckle fractures of the proximal phalanges and torus fractures of the metatarsals and metacarpals are suspicious for abuse. These fractures can be caused by forced extension of the fingers and toes.¹⁷

Nonextremity fractures also should raise significant concerns. Rib, sternal, and scapular fractures suggest a high degree of force not usually seen in accidental trauma.¹⁵ Acute rib fractures are often missed and are more easily identified after callus formation, which may take up to 14 days to become apparent.¹⁸ Skull fractures with questionable history also require further evaluation.

It is important to note that no specific fracture can be considered definitive for nonaccidental trauma, as similar fractures can be caused by abuse or accidental injury.^14,17 Therefore, if suspicion of abuse is present, a skeletal survey must be done. This is the preferred screening study to evaluate for other fractures of abuse.¹⁹ The survey is most useful for children under 2 years of age with concerning extremity, abdominal, and head trauma. For situations with high suspicion, the full skeletal survey should be repeated 14 days later.^4,19

Abusive Head Trauma

Abusive head trauma (AHT) is the most common cause of pediatric deaths related to child abuse.²⁰ The true incidence is unknown because many cases go unreported, and unfortunately, even patients who are seen by clinicians may not have their presentation recognized as AHT. Children under 1 year of age, especially those in the 2- to 6-month age group, are at increased risk for AHT.²⁰