Non-accidental Trauma

Reference work entry


Maltreatment of children may involve physical, emotional, or sexual abuse or neglect. It is too common with an incidence of 9.1/1,000 children. Although there are family- and child-related factors associated with abuse and any age child can be abused, it is the younger infant and child who are most commonly at risk. Early infancy, when crying peaks, is a time of increased risk of abuse and especially abusive head trauma. The diagnosis of non-accidental trauma is based on a detailed history of the injury with documentation of the precise mechanism as reported by the caregiver. The injuries must have an explanation with a plausible mechanism for how they occurred. All states have reporting laws for suspected abuse and provide a degree of immunity for reports made in good faith. The minimal standard of evaluation when abuse is suspected includes a properly done skeletal survey for the 0–24-month-old child, dilated fundoscopic examination by an ophthalmologist, and consultation by the child protective services team. The surgeon may be asked to testify as either a material witness or as an expert witness and so should be well prepared for either role.


Child Abuse Osteogenesis Imperfecta Child Protective Service Skeletal Survey Clavicle Fracture 
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  1. American College of Radiology. ACR practice guideline for skeletal surveys in children. Revised 2011 (Resolution 54). In: American College of Radiology. ACR Standards 2011.Google Scholar
  2. Anderst JD, Carpenter SL, Abshire TC, Section on Hematology/Oncology and Committee on Child Abuse and Neglect of the American Academy of Pediatrics. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013;131(4):e1314–22.PubMedCrossRefGoogle Scholar
  3. Baldwin KD, Scherl SA. Orthopaedic aspects of child abuse. Instr Course Lect. 2013;62:399–403.PubMedGoogle Scholar
  4. Barber I, Perez-Rosello JM, Wilson CR, et al. Prevalence and relevance of pediatric spinal fractures in suspected child abuse. Pediatr Radiol. 2013;43(11):1507–15.Google Scholar
  5. Barr RG, Trent RB, Cross J. Age-related incidence of curve of hospitalized shaken baby syndrome cases: convergent evidence for crying as a trigger to shaking. Child Abuse Negl. 2006;30(1):7–16.PubMedCrossRefGoogle Scholar
  6. Beals RK, Tufts E. Fractured demur in infancy: the role of child abuse. J Pediatr Orthop. 1983;3(5):583–6.PubMedCrossRefGoogle Scholar
  7. Benedict MI, White RB, Wulff LM, et al. Reported maltreatment in children with multiple disabilities. Child Abuse Negl. 1990;14(2):207–17.PubMedCrossRefGoogle Scholar
  8. Bernet W. False statements and the differential diagnosis of abuse allegations. J Am Acad Child Adolesc Psychiatry 1993;32(5):903–10.Google Scholar
  9. Biron D, Shelton D. Perpetrator accounts in infant abusive head trauma brought about by a shaking event. Child Abuse Negl. 2005;29(12):1347–58.PubMedCrossRefGoogle Scholar
  10. Bonkowsky JL, Guenther E, Fillowx FM, et al. Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event. Pediatrics. 2008;122(1):125–31.PubMedCrossRefGoogle Scholar
  11. Carpenter SL, Abshire TC, Anderst JD, Section on Hematology/Oncology and Committee on Child Abuse and Neglect of the American Academy of Pediatrics. Evaluating for suspected child abuse: conditions that predispose to bleeding. Pediatrics. 2013;131(4):e1357–73.PubMedCrossRefGoogle Scholar
  12. Chadwick DL. Preparation for court testimony in child abuse cases. Pediatr Clin North Am. 1990;37(4):955–70.PubMedGoogle Scholar
  13. Christian CW, Block R, Committee on Child Abuse and neglect, American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics. 2009;123(5):1409–11.PubMedCrossRefGoogle Scholar
  14. Currarino G, Birch JG, Herring JA. Developmental coxa vara associated with spondylometaphyseal dysplasia (DCV/SMD): “SMD-corner fracture type” (DCV/SMD-CF) demonstrated in most reported cases. Pediatr Radiol. 2000;30(1):14–24.PubMedCrossRefGoogle Scholar
  15. Davy-Jow SL, Lees DM, Russell S. Virtual forensic anthropology: novel applications of anthropometry and technology in a child death case. Forensic Sci Int. 2013;224(1–3):e7–10.PubMedCrossRefGoogle Scholar
  16. Day F, Clegg S, et al. A retrospective case series of skeletal surveys in children with suspected non-accidental injury. J Clin Forensic Med. 2006;13(2):55–9.PubMedCrossRefGoogle Scholar
  17. Deans KJ, Thackeray J, Askegard-Giesmann JR. Mortality increases with recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg. 2013;75(1):161–5.PubMedCrossRefGoogle Scholar
  18. Dias MS, Smith K, Mazuar P. Preventing abusive head trauma among infants and young children: a hospital-based parent education program. Pediatrics. 2005;115(4):e470–7.PubMedCrossRefGoogle Scholar
  19. Dudley M, Chapman BM. Death of a 6-year-old boy with mental retardation: accident versus child abuse. J Forensic Sci 2012;57(4):1124–8.Google Scholar
  20. Duffy SO, Squires J. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics. 2011;127(1):e47–52.PubMedCrossRefGoogle Scholar
  21. Flaherty EG, MacMillan HL. Committee on Child Abuse and Neglect. From the American Academy of Pediatrics. Clinical Report. Caregiver-Fabricated Illness in a child: A manifestation of child maltreatment. Pediatrics 2013;132(3);590–597.Google Scholar
  22. Gerber P, Coffman K. Nonaccidental head trauma in infants. Childs Nerv Syst. 2007;23(5):499–507.PubMedCrossRefGoogle Scholar
  23. Greeley CS. The evolution of the child maltreatment literature. Pediatrics. 2012;130(2):347.PubMedCentralPubMedCrossRefGoogle Scholar
  24. Greeley CS, Donaruma-Kwoh M, Vettimattam M. Fractures at diagnosis in infants and children with osteogenesis imperfect. J Pediatr Orthop. 2013;33(1):32–6.PubMedCentralPubMedCrossRefGoogle Scholar
  25. Gumbs GR, Keenan HT, Sevick CJ, et al. Infants abusive head trauma in a military cohort. Pediatrics. 2013;132(4):668–76.Google Scholar
  26. Harlan SR, Nixon W, Campbell KA, Hansen K, Prince JS. Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed? Pediatr Radiol. 2009;39:962–8.PubMedCrossRefGoogle Scholar
  27. Harper NS, Eddleman S, Lindberg DM, et al. The utility of follow-up skeletal surveys in child abuse. Pediatrics. 2013;131(3):e672–8.PubMedCrossRefGoogle Scholar
  28. Hennrikus WL, Shaw BA. Injuries when children reportedly fall from a bed or couch. Clin Orthop Relat Res. 2003;407:148–51.PubMedCrossRefGoogle Scholar
  29. Hobbs CJ. ABC of child abuse. Fractures. BMJ. 1989;298:1015–8.PubMedCentralPubMedCrossRefGoogle Scholar
  30. Hudson M, Kaplan R. Clinical response to child abuse. Pediatr Clin North Am. 2006;53(1):27–39.PubMedCrossRefGoogle Scholar
  31. Jenny C. Recognizing and responding to medical neglect. Pediatrics. 2007;120(6):1385–9.PubMedCrossRefGoogle Scholar
  32. Jenny C. Multiple unexplained fractures in infants- the need for clear thinking. Acta Paediatr. 2010;99:491–3.PubMedCrossRefGoogle Scholar
  33. Jenny C, Isaac R. The relation between child death and child maltreatment. Arch Dis Child. 2006;91(3):265–9.PubMedCentralPubMedCrossRefGoogle Scholar
  34. Karmazyn B, Lewis ME, Jennings SG, et al. The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? Am J Roentgenol. 2011;197(1):W159–63.CrossRefGoogle Scholar
  35. Kemp AM, Joshi AH, Mann M, et al. What are the clinical and radiological characteristics of spinal injuries from physical abuse: a systematic review. Arch Dis Child. 2010;95:355–60.PubMedCrossRefGoogle Scholar
  36. Kemp AM, Maguire SA, Nuttal D, et al. Bruising in children who are assessed for suspected physical abuse. Arch Dis Child. 2014;99(2):108–13.Google Scholar
  37. Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA. 1962;181:17–24.PubMedCrossRefGoogle Scholar
  38. Kleinman PK. Diagnostic imaging of child abuse. Baltimore: Williams and Wilkins; 1987.Google Scholar
  39. Kleinman P. Diagnostic imaging of child abuse. 2nd ed. St. Louis: Mosby; 1998.Google Scholar
  40. Kleinman PK, Marks Jr SC. Relationship of the subperiosteal bone collar to metaphyseal lesions in abused infants. J Bone Joint Surg Am. 1995;77(10):1471–6.PubMedGoogle Scholar
  41. Kleinman PK, Perez-Rosselllo JM, Newton AW, et al. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. Am J Roentgenol. 2011;197:1005–8.CrossRefGoogle Scholar
  42. Kleinman PK, Morris NM, Makris J. Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse. AJR Am J Roentgenol. 2013;200(3):641–4.PubMedCrossRefGoogle Scholar
  43. Kowal-Vern A, Paxton TP, et al. Fractures in the under 3 year old age cohort. Clin Pediatr. 1992;31(11):653–9.CrossRefGoogle Scholar
  44. Kravitz H, Driessen G, Gomberg R, et al. Accidental falls from elevated surfaces in infants from birth to 1 year of age. Pediatrics. 1969;44(5):869–76.PubMedGoogle Scholar
  45. Lane WG, Rubin DM. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002;288(13):1603–9.PubMedCrossRefGoogle Scholar
  46. Larimer EL, Fallon SC, Westfall J, et al. The importance of surgeon involvement in the evaluation of non-accidental trauma patients. J Pediatr Surg. 2013;48(6):1357–62.PubMedCrossRefGoogle Scholar
  47. Laskey AL, Stump TE, Hicks RA. Yield of skeletal surveys in children <= 18 months of age presenting with isolated skull fractures. J Pediatr. 2013;162(1):86–9.PubMedCrossRefGoogle Scholar
  48. Leventhal JM, Giather JR. Incidence of serious injuries due to physical abuse in the United States: 1997–2009. Pediatrics. 2012;130(5):847–52.CrossRefGoogle Scholar
  49. Leventhal JM, Martin KD. Fractures and traumatic brain injuries: abuse versus accidents in a US database of hospitalized children. Pediatrics. 2010;126(1):e104–15.PubMedCrossRefGoogle Scholar
  50. Leventhal JM, Thomas SA. Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child. 1993;147(1):8–92.Google Scholar
  51. Leventhal JM, Larson IA, et al. Are abusive fractures in young children becoming less common? Changes over 24 years. Child Abuse Negl. 2007;31(3):311–22.PubMedCrossRefGoogle Scholar
  52. Leventhal JM, Martin KD, et al. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics. 2008;122(3):599–604.PubMedCrossRefGoogle Scholar
  53. Lim HK, Smith WL, Sato Y, et al. Congenital syphilis mimicking child abuse. Pediatr Radiol. 1995;25(7):560–1.PubMedCrossRefGoogle Scholar
  54. Lindberg DM, Harper NS, Laskey AL, et al. Prevalence of abusive fractures of the hands, feet spine or pelvis on skeletal survey: perhaps “uncommon” is more common than suggested. Pediatr Emerg Care. 2013;29(1):26–9.PubMedCrossRefGoogle Scholar
  55. Maguire SA, Kemp AM, Lumb RC, et al. Estimating the probability of abusive head trauma: a poled analysis. Pediatrics. 2011;128(3):e550.PubMedGoogle Scholar
  56. Maguire SA, Upadhyaya M, Evans A. A systematic review of abusive visceral injuries in childhood-their range and recognition. Child Abuse Negl. 2013;37(7):430–45.PubMedCrossRefGoogle Scholar
  57. Mandelstam SA, Cook D, et al. Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child. 2003;88(5):387–90.PubMedCentralPubMedCrossRefGoogle Scholar
  58. Marlowe A, Pepin MG, Byers PH. Testing for osteogenesis imperfect in cases of suspected nonaccidental injury. J Med Genet. 2002;39(6):383–6.CrossRefGoogle Scholar
  59. McMahon P, Grossman W, Gaffney M, et al. Soft-tissue injury as an indication of child abuse. J Bone Joint Surg Am. 1995;77(8):1179–83.PubMedGoogle Scholar
  60. McMillan JH, Yang M, Jones HR. Brachial plexopathy and nonaccidental injury: role of the neurologist. J Child Neurol. 2010;25(5):620–2.PubMedCrossRefGoogle Scholar
  61. Melville JD, Lukefahr JL, Clarke EA. First rib fractures in abused infants: a report of 3 cases. Clin Pediatr. 2012;51(5):426–30.CrossRefGoogle Scholar
  62. Mungan NK. Update on shaken baby syndrome: ophthalmology. Curr Opin Ophthalmol. 2007;18(5):392–7.PubMedCrossRefGoogle Scholar
  63. Nimkin K, Spevak MR, Kleinman PK. Fractures of the hands and feet in child abuse: imaging and pathologic features. Radiology. 1997;203(1):233–6.PubMedCrossRefGoogle Scholar
  64. Ortega HW, Vleden HV, Kreykes NS. Childhood death attributable to trauma: is there a difference between accidental and abusive fatal injuries? J Emerg Med. 2013;45(3):332–7.PubMedCrossRefGoogle Scholar
  65. Pandya NK, Baldwn KD. Humerus fractures in the pediatric population: an algorithm to identify abuse. J Pediatr Orthop B. 2010;19(6):535–41.PubMedCrossRefGoogle Scholar
  66. Parizel PM, Ceulemans B, Laridon A, et al. Cortical hypoxic-ischemic brain damage in shaken-baby (shaken impact) syndrome: value of diffusion-weighted MRI. Pediatr Radiol. 2003;33(12):868–71.PubMedCrossRefGoogle Scholar
  67. Parks SE, Annest JL, Hill HA, Karch DL. Pediatric abusive head trauma: recommended definitions for public health surveillance and research. Atlanta: Centers for Disease Control and Prevention; 2012.Google Scholar
  68. Pergolizzi R, Oestreich AE. Child abuse fracture through physiologic periosteal reaction. Pediatr Radiol. 1995;25(7):566–7.PubMedCrossRefGoogle Scholar
  69. Piteau SJ, Ward MGK, Barrowman NJ. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012;130(2):315–23.PubMedCrossRefGoogle Scholar
  70. Preer G, Sorrentino D, Newton AW. Child abuse pediatrics: prevention, evaluation, and treatment. Curr Opin Pediatr. 2012;24(2):266–73.PubMedCrossRefGoogle Scholar
  71. Preer G, Sorrentino D, Ryznar E. Child maltreatment: promising approaches and new directions. Curr Opin Pediatr. 2013;25(2):268–74.PubMedCrossRefGoogle Scholar
  72. Proisy M, Marchand AJ, Loget P. Whole-body post-mortem computed tomography compared with autopsy in the investigation of unexpected death in infants and children. Eur Radiol. 2013;23(6):1711–9.PubMedCrossRefGoogle Scholar
  73. Prosser I, Lawson Z, Evans A. A timetable for the radiologic features of fracture healing in young children. Am J Roentgenol. 2012;198(5):1014–20.CrossRefGoogle Scholar
  74. Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics. 2010;125(1):60–6.PubMedCrossRefGoogle Scholar
  75. Schnitzer P. Child deaths resulting from inflicted injuries: household risk factors and perpetrator characteristics. Pediatrics. 2005;116:687–93.CrossRefGoogle Scholar
  76. Schwartz AJ, Ricci LR. How accurately can bruises be aged in abused children? Literature review and synthesis. Pediatrics. 1996;97(2):254–7.PubMedGoogle Scholar
  77. Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop. 2000;20(4):475–81.PubMedGoogle Scholar
  78. Section on Radiology: American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics. 2009;123(5):1430–5.CrossRefGoogle Scholar
  79. Shaw BA, Murphy KM, et al. Humerus shaft fractures in young children: accident or abuse? J Pediatr Orthop. 1997;17(3):293–7.PubMedGoogle Scholar
  80. Sheets LK, Leach ME, Koszewski IJ. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701–7.PubMedCrossRefGoogle Scholar
  81. Singh R, Squires J, Fromkin JB. Assessing the use of follow-up skeletal surveys in children with suspected physical abuse. J Trauma Acute Care Surg. 2012;73(4):972–6.PubMedCrossRefGoogle Scholar
  82. Skellern CY, Wood DO. Non-accidental fractures in infants: risk of further abuse. J Paediatr Child Health. 2000;36(6):590–2.PubMedCrossRefGoogle Scholar
  83. Starling SP, Patel S, Burke BL, et al. Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med. 2004;158(5):454–8.PubMedCrossRefGoogle Scholar
  84. Steiner RD, Pepin M, Byers PH. Studies of collagen synthesis and structure in differentiation of child abuse from osteogenesis imperfect. J Pediatr. 1996;128(4):542–7.PubMedCrossRefGoogle Scholar
  85. Strait RT, Siegel RM. Humeral fractures without obvious etiologies in children less than 3 years of age: when is it abuse? Pediatrics. 1995;96:667–71.PubMedGoogle Scholar
  86. Taitz J, Moran K. Long bone fractures in children under 3 years of age: is abuse being missed in emergency department presentation? J Paediatr Child Health. 2004;40(4):170–4.PubMedCrossRefGoogle Scholar
  87. Tenenbaum S, Thein R, Herman A. Pediatric nonaccidental injury: are orthopedic surgeons vigilant enough? J Pediatr Orthop. 2013;33(2):145–51.PubMedCrossRefGoogle Scholar
  88. Thompson A, Bertocci G, Pierce MC. Assessment of internal potential in pediatric bed fall experiments using an anthropomorphic test devise. Accid Anal Prev 2013;50:16–24.Google Scholar
  89. Thomas SA, Rosenfield NS. Long-bone fractures in young children: distinguishing accidental injuries from child abuse. Pediatrics. 1991;88(3):471–6.PubMedGoogle Scholar
  90. Thomas AG, Hegde SV, Dineen RA. Patterns of accidental craniocerebral injury occurring in early childhood. Arch Dis Child. 2013;98(10):787–92.PubMedCrossRefGoogle Scholar
  91. Tsai A, Coats B, Kleinman PK. Stress profile of infant rib in the setting of child abuse: a finite element parametric study. J Biomech. 2012;45(11):1861–8.PubMedCrossRefGoogle Scholar
  92. Wood JN, Feudtner C, Medina SP, et al. Variation in occult injury screening for children with suspected abuse in selected US children’s hospitals. Pediatrics. 2012;130(5):853–60.PubMedCentralPubMedCrossRefGoogle Scholar
  93. Wood JN, Fakeye O, Feudtner C. Development of guidelines for skeletal survey in young children with fractures. Pediatrics 2014;134(1):45–53Google Scholar
  94. Wygnanski-Jaffe T, Levin AV, Shafiq A, et al. Postmortem orbital findings in shaken baby syndrome. Am J Opthalmol. 2006;142(2):233–40.CrossRefGoogle Scholar

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© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Division of OrthopaedicsChildren’s Mercy HospitalKansas CityUSA

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