summary Pediatric Abuse is the second most common cause of death in children and 50% of fractures in children younger than 1 year of age are attributable to abuse. Diagnosis can be suspected with a pediatric injury that is inconsistent with the mechanism of injury, a delay in seeking care, long bone fractures in nonambulatory child, or presence of highly specific fractures. Treatment involves reporting abuse to the appropriate agency and hospital admission for multidisciplinary evaluation. Rarely, operative management of fractures may be required. Epidemiology Incidence >1 million children are victims of substantiated abuse or neglect in United States each year child abuse is the second most common cause of death in children behind accidental injury head injury is the most frequent cause of long term physical morbidity in the child Demographics 90% of fractures due to abuse occur in children younger than 5 years of age 50% of fractures in children younger than 1 year of age are attributable to abuse 30% of fractures in children younger than 3 years of age are attributable to abuse the most common cause of femur fractures in the nonambulatory infant is nonaccidental trauma Social risk factors child first-born unplanned pregnancy premature disabilities (cerebral palsy) step-children parent single-parent home recent social stressor (move, job loss) unemployment drug use personal history of abuse as a child lower socioeconomic status lack of support system Types (can have more than one type present): neglect 78% physical abuse 18% sexual 9% psychological 8% Presentation History injury often inconsistent with history red flags delay in seeking care no history of injury or inconsistent story high specificity fractures login to view 15 more bullets moderate specificity fractures login to view 4 more bullets other injuries concerning for abuse - multiple bruises, burns Symptoms pain related to fractures fractures are the second most common lesion in abused children login to view 3 more bullets Physical exam skin lesions most common presenting lesion Imaging Radiographs recommended views AP and lateral of bone or joint of suspicion initial evaluation should include skeletal survey Bone scan alternative or adjunct to the radiographic skeletal survey in selected cases, particularly for children older than 1 year of age provides increased sensitivity for detecting rib fractures, subtle shaft fractures, and areas of early periosteal elevation not useful in metaphyseal or cranial fractures Differential True accidental injury Osteogenesis imperfecta Osteopenia of prematurity Scurvy Copper deficiency Menkes disease Disuse osteopenia (nonambulatory or minimally ambulatory children) Chronic disease (kidney and liver) Treatment Nonoperative report abuse to appropriate agency indications login to view 3 more bullets hospital admission indications login to view 3 more bullets cast application indications login to view 1 more bullet Operative rarely neccessary definitive treatment as indicated for particular injury Prognosis If unreported 30-50% chance of repeat abuse 5-10% chance of death from abuse