Comprehensive new guidelines released by the American Academy of Pediatrics (AAP) share updated recommendations for evaluating fractures in young children when child abuse is suspected.

The clinical report, published in Pediatrics, provides detailed guidance on conducting thorough medical evaluations while considering differential diagnoses.

The report emphasized that fractures are the second most common injury in child physical abuse cases after bruising. Up to 20% of fractures caused by abuse in children younger than 3 years may initially be misdiagnosed as unintentional or attributed to other causes.

"An appropriate diagnosis of abuse involves a thorough history and physical examination, including the age and developmental ability of the child; the reported mechanism, location, and type(s) of fracture; and the presence of other injuries," the report's authors wrote.

The guidelines outline specific red flags that should raise suspicion for abuse, including:

• No history of injury

• History inconsistent with the type of fracture or required force

• Fractures in nonambulatory children

• Multiple fractures or fractures of different ages

• Delay in seeking medical care.

For imaging recommendations, the guidelines state that children younger than 24 months presenting with fractures concerning for abuse should receive a skeletal survey. Additional fractures are identified in approximately 10% of skeletal surveys, with infants having the highest yield at 13% to 26%. Head CT is recommended for children under 6 months to evaluate for occult head injury, and follow-up skeletal surveys conducted approximately 2 weeks later can identify fractures missed in initial imaging or clarify equivocal findings.

The report also specifies laboratory tests that should be part of the evaluation, including serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and 25-hydroxyvitamin D. These tests help assess underlying medical conditions such as metabolic bone disease or nutritional deficiencies that could predispose children to fractures.

Certain fracture patterns carry higher specificity for abuse, particularly in infants:

• Rib fractures (especially posterior)

• Classic metaphyseal lesions

• Scapular fractures

• Spinous process fractures

• Sternal fractures.

However, the authors emphasize that "no fracture pattern can exclude child abuse." Thorough laboratory and imaging workups are essential to evaluate for underlying medical conditions that could predispose to fractures.

For siblings and household contacts of children with confirmed abuse, the guidelines recommend evaluation, as they face increased risk. One cited study found that in households with an abused child, all siblings in 37% of cases and some siblings in 20% of cases had also experienced maltreatment.

The report provides extensive guidance on differentiating between abusive and non-abusive fractures while acknowledging diagnostic challenges. It stresses the importance of evidence-based differential diagnoses and appropriate evaluation strategies when assessing children with concerning fractures.

Full disclosures can be found in the guidelines.