Nonaccidental Trauma


Nonaccidental Trauma


The spectrum of child maltreatment includes neglect, psychological abuse, sexual abuse, and physical abuse (sometimes called nonaccidental trauma).

In 2018, more than 678,000 cases of child maltreatment reported to child protective services in the United States were confirmed; at least 1,770 deaths were caused by child maltreatment.

Fractures are the second most common type of injury caused by child abuse.

Up to 20% of fractures in infants and toddlers are due to abuse.

About 80% of all fractures caused by abuse occur in children younger than 18 months.

In more than 80% of cases, a parent is the abuser.

Children who have been abused may have identifiable risk factors associated with abuse. However, the absence of risk factors does not rule out abuse.

Risk factors associated with child abuse are listed in Box 49-1.

Signs and Symptoms of Child Physical Abuse

Caregiver provides an explanation for an injury that does not match the mechanism causing the injury.

Caregiver provides no explanation for an injury that could only occur with caregiver knowledge of the event; for example, no trauma history for a humeral fracture in an infant 3 months of age.

Child is too young or developmentally incapable of causing the injury described; for example, 4 months of age with a “toddler” fracture.

There is a delay in seeking care for a symptomatic injury.

Soft tissue injuries are the most common physical findings in the abused child. Consider abuse if

Bruises, ecchymoses, and other soft tissue injuries are on the cheeks, ears, neck, back, buttocks, chest, abdomen, or genitourinary area, or over other non-bony areas (eg, frenulum)

Child is not yet cruising

Bruise has a pattern of an object or instrument (eg, loop marks)

Child has multiple bruises (> 4) and bruises in clusters

Fractures can be caused by child abuse or result from non-inflicted trauma, and determining the cause can be difficult.

Consider child abuse if

History provided is inconsistent with the mechanism of the type of fracture

Box 49-1. Factors and Characteristics That Place a Child at Risk for Maltreatment


Emotional/behavioral difficulties

Chronic illness

Physical disabilities

Developmental disabilities

Preterm birth

Unwanted child

Unplanned pregnancy


Low self-esteem

Poor impulse control

Substance abuse/alcohol abuse

Young maternal or paternal age

Parent abused as a child

Depression or other mental illness

Poor knowledge of child development or unrealistic expectations for child

Negative perception of normal child behavior

Environment (community and society)

Social isolation



Low educational achievement

Single parent

Nonbiologically related male living in the home

Family or intimate partner violence

From Flaherty EG, Stirling J; American Academy of Pediatrics Committee on Child Abuse and Neglect. The pediatrician’s role in child maltreatment prevention. Pediatrics. 2010;126(4):833–841.

Child has multiple fractures or fractures in different stages of healing

Child has other evidence of abuse or neglect (eg, bruises or injuries to other parts of the body)

Fractures with a high specificity for child abuse

Rib fracture

Classic metaphyseal lesion (corner fracture)

Scapular fractures

Spinous process fractures

Sternal fractures

Long bone fractures can be caused by child abuse (any long bone fracture in a child who is not yet ambulatory is a cause for concern).

Spiral fractures can be non-inflicted or caused by child abuse.

Transverse fractures are more commonly associated with child abuse than are spiral fractures.

A single, isolated fracture is more common than multiple fractures.

Long bone fracture mechanisms

Transverse fractures are caused by compressive and tensile loads applied perpendicular to the bone (ie, bending). A high-impact load applied to a single location can cause a transverse fracture.

Spiral fractures are caused by torsional loading of the bone (ie, twisting).

Buckle or torus fractures are caused by compressive or axial loading of the bone.

Oblique fractures are caused by a combination of torsional and bending loads applied to the bone.

Differential Diagnosis of Fractures

Non-inflicted (unintentional) trauma

Osteogenesis imperfecta (OI)

OI is much less common than child abuse. Children with OI may also be abused.

No formal screening guidelines for OI currently exist. Genetic testing may be recommended.

Suspect OI if there is a family history of OI, multiple fractures, or early-onset hearing loss, or if the patient has blue sclera or osteopenic bones on skeletal survey.


Bones have characteristic radiologic appearance

Osteopenia of prematurity

Neonates born at less than 28 weeks of gestation or who weigh less than 1,500 g at birth are more vulnerable, particularly if they have received prolonged total parenteral nutrition, have bronchopulmonary dysplasia, or have received a prolonged course of diuretics or steroids.

Preterm neonates may have osteopenic bones, but they are also more vulnerable to being abused.

Other genetic/metabolic disorders may predispose to fractures, but typically have other key findings suggesting an underlying abnormality.

Diagnostic Considerations

A high index of suspicion for inflicted trauma must be maintained when evaluating any child with a fracture or other musculoskeletal injury.

A detailed history about the event causing the fracture should be sought.

Specific details about the patient’s activity and position just prior to and immediately following the injury event may provide information about the mechanism.

If a history of trauma is described, determine if it is a plausible cause for the injuries sustained, with careful consideration of the child’s developmental capabilities.

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Mar 12, 2022 | Posted by in ORTHOPEDIC | Comments Off on Nonaccidental Trauma

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