First and second year — the floor first, then every step
A complete skeletal survey to the published standard, read for the high-specificity fractures (classic metaphyseal lesions, posterior rib fractures), fractures of different ages, and fractures the history does not explain — with head imaging and a follow-up survey at about two weeks.
Orient first
Specificity differs by fracture: classic metaphyseal lesions, posterior rib fractures, scapular, spinous process and sternal fractures are highly specific for abuse in infants; a single diaphyseal fracture is common in both abuse and accidents.
Healing rib fractures are often visible only on the follow-up survey — callus appears about 10–14 days after injury.
The radiologist's role is to describe the fractures, their likely ages, and whether the explanation given accounts for them — and to communicate directly with the safeguarding team.
Acquire the study
Full skeletal survey per the ACR/SPR or RCR/SCoR protocol, including bilateral oblique rib views; follow-up survey at about 11–14 days (limited protocols vary — verify local practice).
The manoeuvre
Metaphyses of every long bone on the AP and lateral views: the CLASSIC METAPHYSEAL LESION — a corner fracture or a bucket-handle lucency across the metaphysis.
Ribs on the AP and both oblique views: POSTERIOR rib fractures beside the costovertebral junction, and lateral and anterior fractures; callus on follow-up.
Skull on two views: fracture pattern, complexity, crossing sutures.
Spine (lateral), scapulae, sternum, hands and feet.
Estimate the age of each fracture from periosteal reaction, soft callus, hard callus and remodelling — as a range, not a date.
What confirms it
High-specificity fractures, multiple fractures of different ages, or fractures inconsistent with the stated mechanism or the child's development.
What licenses you to exclude it
A normal initial survey does not exclude rib fractures; the follow-up survey is part of the examination.
The classic misread
Calling a normal metaphyseal variant (a step-off or spur at the distal femur or proximal tibia) a classic metaphyseal lesion — compare with the other side.
Dating fractures precisely — give ranges and state the uncertainty.
Reporting the injury
Classification to use
Specificity tiers (high: classic metaphyseal lesions, posterior rib, scapular, spinous process, sternal fractures; moderate: multiple or bilateral fractures, fractures of different ages, vertebral body, digital and complex skull fractures; common/low: subperiosteal new bone, clavicle, long-bone shaft, linear skull fractures).
Measurements — and how to take them
Not measurement-driven; the age estimate is expressed as a range from the healing stage.
What to report
Every fracture with site, type and estimated age range; high-specificity findings named as such; the adequacy of the survey; head imaging findings; a recommendation for the follow-up survey; the medical differential where relevant.
That the findings have been communicated to the safeguarding or child-protection team, to whom and when.
How to report it
X-ray: "Classic metaphyseal lesions of the distal left femur and proximal right tibia, and healing fractures of the posterior right 6th to 8th ribs with callus (estimated 2–4 weeks old). These fractures have a high specificity for inflicted injury. No explanatory history is recorded. Findings discussed with the safeguarding paediatrician at 16:40. Follow-up skeletal survey recommended in 11–14 days."
What not to report
Do not state that abuse "has occurred" — describe specificity and consistency with the history; the diagnosis is multidisciplinary.
Do not give a single date for a fracture — give a range.
Associated injuries to look for
Intracranial injury (subdural haemorrhage), abdominal visceral injury, and injuries in siblings (screening per local policy).
What changes management
Any high-specificity finding — immediate safeguarding referral and head imaging.
The follow-up survey can change the conclusion.
Reference values
Each value carries the caveat that keeps it from being misused. Normal limits and diagnostic criteria are kept apart on purpose: a disease cut-off read as a normal range is the more dangerous mistake.
Diagnostic criteria
Metaphysis (CML) · Classic metaphyseal lesion versus buckle
absent; a named corner / bucket-handle metaphyseal fracture is a high-specificity inflicted-injury pattern, and it is not the already-registered Salter–Harris type by itself
A CML is not a toddler’s buckle. The survey, not a single film, is the test.
X-ray · paediatric
Ribs (posterior) · Posterior-rib fracture in the infant
absent; posterior-rib fractures in a non-ambulant infant are a high-specificity inflicted-injury pattern — they are not the already-registered rib-notching entry
Obliques and a follow-up survey show what the first film misses. Healing callus is the clock.
X-ray · CT · paediatric
See it on real cases
Direct links to Radiopaedia — the reference article and worked cases with their images. Each opens on Radiopaedia.