Bridging Impact Physics to Clinical Judgment: Differentiating Non-Accidental Trauma from Accidental Injury with a Framework for Pediatric Forensic Assessment

A persistent clinical and forensics issue is distinguishing accidental injury from inflicted trauma in pediatrics. Missed abuse may expose children to repeated or fatal abuse, while false positives and overinterpretation of nonspecific findings can lead to unjustified investigations, potential separation, and harm to innocent families. These high-stakes leave clinicians an exceptionally low margin of error. Incomplete histories, variable injury biomechanics, developmental differences, inconsistent diagnostic pathways, and medical, dermatological, or cultural mimics often complicate assessment. Objective This review aims to synthesize existing biomechanical and physical evidence involving low-velocity falls with bruising decision approaches, anatomical injury mapping, differential diagnosis, laboratory evaluation, and age-influenced imaging into a reliable framework for pediatric forensic assessment through a physics-to-bedside analysis. Methods This review examined finite element modeling, the biomechanics of pediatric injury, prospective studies, the TEN-4-FACESp decision framework, pediatric radiology, multidisciplinary child abuse evaluations, and papers regarding hematological, connective tissue, skeletal, dermatological, and cultural mimics of abuse. Each section is analyzed for limitations. Biomechanical plausibility was considered in relation to fall height, impact orientation, surface compliance, loading, and the limitations of models and physics when considering abuse. Isolated findings were evaluated as probabilistic rather than absolute proof. Findings Existing biomechanical studies show that the probability of injury depends on the interaction of multiple variables, including impact surface and condition, direction, fall orientation, developmental stage and anatomy, and tissue properties. TEN-4-FACESp is useful for identifying bruising patterns, but it is a screening tool. Therefore, if the results are concerning, they warrant further evaluation, and cannot independently establish abuse. Assessment must integrate physical examination, developmental history, medical baselines, neuroimaging as necessary, skeletal imaging, and multidisciplinary review. Conclusions The proposed framework can reduce reliance on intuition or isolated findings and can improve the accuracy as well as transparency of pediatric forensic reasoning. It cannot eliminate uncertainty independently. The framework is based on the testing of whether the reported mechanism is both physically and medically compatible with the observed findings. It includes appropriate consideration of abuse, accidental injury, and alternative explanations such as dermatological or cultural mimics and underlying medical conditions. Before this framework can be considered a validated clinical approach, multicenter validation, standardized imaging and laboratory pathways, and biomechanical models are required.