The skeletal survey should determine a level of specificity based on the nature, location, and chronicity of injury; however, no fracture in itself is pathognomic for child abuse. Fractures with high specificity of child abuse include rib fractures (especially posterior), classic metaphyseal lesions, scapular fractures, spinous process fractures, and sternal fractures. The classic metaphyseal lesions (Fig. 30.15a) are also known as corner or bucket-handle fractures, commonly caused by shearing force in manual assaults. Rib fractures are highly specific findings of abuse in cases of traumatic brain lesion, and they usually result from severe squeezing and shaking of the chest (Fig. 30.15b). Fractures with moderate specificity comprise multiple fractures, fractures of different ages, epiphyseal separations, vertebral body fractures and subluxations, digital fractures in nonambulatory children (Fig. 30.15c), and complex skull fractures. Common skeletal injuries with low specificity for child abuse consist of clavicular fractures (Fig. 30.15b), long bone shaft fractures, linear skull fractures, and subperiosteal new bone formation (Kleinman 1998; van Rijn and Sieswerda-Hoogendoorn 2012).

Metabolic bone disease such as rickets, skeletal dysplasia, osteogenesis imperfecta, and osteomyelitis can mimic child abuse. Thus, they should be excluded as a predisposing cause of multiple fractures.