Fractures and visceral injuries in child abuse
- Finding
In infants, classic metaphyseal lesions and posterior rib fractures strongly suggest abuse; abdominal injuries can easily be missed.
What it is
Fractures are the second most common finding in physical abuse after skin injuries, and the younger the child the more suspicious they are, especially before the child can walk. Some are highly specific: the classic metaphyseal lesion of the long bones and posterior rib fractures in infants. Multiple fractures, fractures of different ages and fractures that do not fit the mechanism described also point to abuse. Abdominal injuries (liver, duodenum, pancreas, bowel) may leave no bruise on the abdominal wall and present with vague signs, so they are looked for even without symptoms. Bone diseases and normal variants must be ruled out before concluding.
How to tell it apart
- Typically accidental fractures: spiral tibial fracture in a child starting to walk, supracondylar fracture from a fall in an older child, clavicle from birth.
- Osteogenesis imperfecta, rickets and other bone diseases: look for blue sclerae, family history, bone density and laboratory tests.
- Normal metaphyseal variants can be mistaken for the classic metaphyseal lesion: an experienced paediatric radiologist should read the images.
- Combined solid-organ and hollow-viscus injury is more common in abuse than in accidental trauma.
- Delay in seeking care also happens with accidental abdominal injuries: on its own it does not prove abuse.
How to recognise it
- Classic metaphyseal lesion: a transverse fracture through the metaphysis of a long bone in infants under one year, seen as a «corner» or «bucket-handle» fracture.
- Posterior rib fractures, close to the spine, often multiple and on both sides.
- Multiple fractures or callus at different stages of healing.
- Complex or bilateral skull fractures with a history of a minor fall.
- Liver laceration, duodenal haematoma, pancreatic injury or bowel perforation, often with no visible bruise on the abdominal wall.
How it forms
- The metaphyseal lesion is caused by violent pulling or twisting of a limb, or when the limbs flail as the child is shaken.
- Posterior rib fractures are caused by squeezing the infant's chest hard between the hands, levering the ribs over the spine.
- Blows to the abdomen crush the viscera against the spine; shearing forces tear the bowel at fixed points such as the duodenojejunal junction.
Next step: what to do and document
- In children under two with suspected abuse, order a full skeletal survey and consider repeating it later to show fractures that become visible as callus forms.
- Order transaminases and, if they are raised or there are abdominal signs, abdominal imaging; paediatric guidelines include them in the abuse work-up.
- Describe each fracture with its site, type and signs of healing, and ask for a paediatric radiologist's report.
- Rule out bone disease with the family history, examination of sclerae and teeth, and bone metabolism tests.
- Report the suspicion and activate ICBF protection; if the child dies, the medico-legal autopsy is mandatory (Decree 786 of 1990, art. 7(d)).
- Official text checked on 2026-11-13 at funcionpublica.gov.co.
Common mistakes
- Not doing a full skeletal survey in a child under two with suspected abuse.
- Blaming an infant's rib fractures on resuscitation without analysing their location.
- Not ordering transaminases or abdominal imaging when abuse is suspected, even without symptoms.
- Dating fractures to the day: radiological dating is approximate.
Test yourself
Think of the answer, then tap the question to see it.
Which fractures in an infant are most specific for abuse?
The classic metaphyseal lesion of the long bones and posterior rib fractures.
How are posterior rib fractures produced in infant abuse?
By squeezing the chest hard between the hands, which levers the ribs over the spine.
Which laboratory test helps detect hidden abdominal injuries in a child with suspected abuse?
Liver transaminases; if they are raised, abdominal imaging follows.
Which disease must be ruled out when an infant has multiple fractures?
Osteogenesis imperfecta, along with other bone diseases such as rickets.
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Educational content on forensic and legal medicine; not legal advice and no substitute for the technical guides of Colombia's National Institute of Legal Medicine and Forensic Sciences. Laws change: each page links the official text and says when it was last checked. For a real case, follow the guide in force and ask the competent authority.
Sources: Can metaphyseal variations in the distal femurs and proximal tibias be distinguished from classic metaphyseal lesions? (Pediatric Radiology (PMC), 2025); Imaging and clinical features of intra-abdominal injuries in children with suspected physical abuse (Pediatric Radiology (PMC), 2026); Decreto 786 de 1990: autopsias clínicas y médico-legales y viscerotomías (compilado en el Decreto 780 de 2016) (Función Pública, Gestor Normativo, 1990).
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