Intended for healthcare professionals


Patterns of skeletal fractures in child abuse: systematic review

BMJ 2008; 337 doi: (Published 02 October 2008) Cite this as: BMJ 2008;337:a1518
  1. Alison M Kemp, reader in child health1,
  2. Frank Dunstan, professor of medical statistics1,
  3. Sara Harrison, consultant paediatric radiologist2,
  4. Susan Morris, consultant paediatric radiologist2,
  5. Mala Mann, information specialist3,
  6. Kim Rolfe, research officer1,
  7. Shalini Datta, consultant radiologist2,
  8. D Phillip Thomas, consultant in orthopaedics4,
  9. Jonathan R Sibert, emeritus professor of child health1,
  10. Sabine Maguire, senior lecturer in child health1
  1. 1Welsh Child Protection Systematic Review Group, Clinical Epidemiology Interdisciplinary Research Group, School of Medicine, Cardiff University, University Hospital of Wales Heath Park, Cardiff CF 2XX
  2. 2Radiology Department, Cardiff and Vale NHS Trust, School of Medicine, Cardiff University
  3. 3Support Unit for Research Evidence, Cardiff University
  4. 4Orthopaedic Department, Cardiff and Vale NHS Trust, School of Medicine, Cardiff University
  1. Correspondence to: A Kemp kempam{at}
  • Accepted 22 July 2008


Objectives To systematically review published studies to identify the characteristics that distinguish fractures in children resulting from abuse and those not resulting from abuse, and to calculate a probability of abuse for individual fracture types.

Design Systematic review.

Data sources All language literature search of Medline, Medline in Process, Embase, Assia, Caredata, Child Data, CINAHL, ISI Proceedings, Sciences Citation, Social Science Citation Index, SIGLE, Scopus, TRIP, and Social Care Online for original study articles, references, textbooks, and conference abstracts until May 2007.

Study selection Comparative studies of fracture at different bony sites, sustained in physical abuse and from other causes in children <18 years old were included. Review articles, expert opinion, postmortem studies, and studies in adults were excluded.

Data extraction and synthesis Each study had two independent reviews (three if disputed) by specialist reviewers including paediatricians, paediatric radiologists, orthopaedic surgeons, and named nurses in child protection. Each study was critically appraised by using data extraction sheets, critical appraisal forms, and evidence sheets based on NHS Centre for Reviews and Dissemination guidance. Meta-analysis was done where possible. A random effects model was fitted to account for the heterogeneity between studies.

Results In total, 32 studies were included. Fractures resulting from abuse were recorded throughout the skeletal system, most commonly in infants (<1 year) and toddlers (between 1 and 3 years old). Multiple fractures were more common in cases of abuse. Once major trauma was excluded, rib fractures had the highest probability for abuse (0.71, 95% confidence interval 0.42 to 0.91). The probability of abuse given a humeral fracture lay between 0.48 (0.06 to 0.94) and 0.54 (0.20 to 0.88), depending on the definition of abuse used. Analysis of fracture type showed that supracondylar humeral fractures were less likely to be inflicted. For femoral fractures, the probability was between 0.28 (0.15 to 0.44) and 0.43 (0.32 to 0.54), depending on the definition of abuse used, and the developmental stage of the child was an important discriminator. The probability for skull fractures was 0.30 (0.19 to 0.46); the most common fractures in abuse and non-abuse were linear fractures. Insufficient comparative studies were available to allow calculation of a probability of abuse for other fracture types.

Conclusion When infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive cause. During the assessment of individual fractures, the site, fracture type, and developmental stage of the child can help to determine the likelihood of abuse. The number of high quality comparative research studies in this field is limited, and further prospective epidemiology is indicated.


  • Contributors: AMK is the research programme director, was responsible for methodology and data analysis, and did reviews. FD did the statistical analysis. SD, SH, and SM were the main radiology reviewers, checked and agreed the radiology detail of the review quality standards, and were involved in data analysis and writing the manuscript. MM did literature searches. PT was the orthopaedic adviser to the project, did reviews, and checked the orthopaedic content of the paper. JRS acted as project co-director, reviewer, and paediatric adviser to the project. SM was the principal investigator, did reviews, scanned studies for relevance, compiled the appendix, and analysed data. KR contributed editorial work on the manuscript and management of the review process, provided methodological data on the review process, and compiled website content at AMK is the guarantor.

  • Review team: M Barber, P Barnes, M Bhal, A Butler, J Bowen, R Brooks, S Datta, B Ellaway, R Frost, C Graham, S Harrison, M James-Ellison, N John, A Kemp, A Maddocks, S Maguire, S Morris, A Mott, A Naughton, C Norton, H Payne, L Price, I Prosser, J Sibert, P Thomas, E Webb, C Woolley.

  • Funding: National Society for the Prevention of Cruelty to Children, which is independent of the study group.

  • Competing interests: None declared.

  • Ethical approval: Not needed.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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