Peer-reviewed article
Fractures in suspected child abuse: A critical review of the evidence cited by the American Academy of Pediatrics and Royal College of Paediatrics and Child Health.
Chris Brook, Julie Mack, Waney Squier, Ankin Güvencel, Cyrille Rossant et al. ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This paper critically reviews the scientific evidence that two major medical organizations (American Academy of Pediatrics and Royal College of Paediatrics and Child Health) use to link fractures with child abuse. The authors examined 67 studies and found that all had significant methodological weaknesses, particularly problems with how abuse cases were identified and diagnosed. The review concludes that the evidence used to guide medical professionals in identifying abuse through fracture patterns is much weaker than current guidance suggests.
Key points
- All 67 identified studies were observational, mostly retrospective designs with no independent gold standard for diagnosing abuse
- 35 of 67 studies reported measures of diagnostic utility for fractures in suspected abuse
- No study used a truly independent method to confirm whether abuse had occurred, instead relying on case classification methods that varied widely
- Key methodological limitations include incorporation bias and circular reasoning in how cases were classified
- The evidence quality is substantially limited, creating uncertainty about which fracture patterns reliably indicate abuse
Limitations
This is a critical review of existing literature rather than a primary study, so it cannot provide new empirical data about fracture patterns in abused children. It focuses on methodological critique rather than examining what alternative diagnostic approaches might be more reliable.
Abstract
We critically evaluated the evidence cited by the American Academy of Pediatrics (AAP) and the Royal College of Paediatrics and Child Health (RCPCH) supporting the diagnostic significance of fractures in suspected physical child abuse. Primary studies cited by the AAP Clinical Report and the RCPCH Systematic Review were reviewed with respect to study design, methods used to classify cases as abuse, and the potential for incorporation bias and outcome misclassification. Sixty-seven studies were identified, of which 35 reported measures of diagnostic utility. All were observational, predominantly retrospective studies. No study employed an independent gold standard for the diagnosis of abuse, and all relied on imperfect reference standards that varied in their methods of case classification. The evidence demonstrated substantial methodological limitations, primarily the risks of incorporation bias and circular reasoning. Overall, the evidence underpinning current guidance on fractures in suspected child abuse is characterised by methodological flaws that limit the scientific confidence that can be placed in the reported diagnostic associations. The substantial uncertainty surrounding the diagnostic significance attributed to fractures in the evaluation of suspected child abuse should be explicitly recognised and communicated.