Clinical and radiographic features of fractures raising suspicion of non-accidental trauma in young children: A retrospective emergency department study

Purpose To explore clinical and radiographic patterns that may generate hypotheses regarding early indicators of non-accidental trauma (NAT). Methods This retrospective observational study included 649 children aged 0–6 years who presented to a tertiary pediatric emergency department between January 2023 and December 2024. Fractures were classified as moderate- or high-specificity injuries according to established NAT criteria. For children classified as having possible abuse, records were reviewed for abuse notification and protective-care placement. Results The median age was 40 months, and 54.4% of participants were male. Fractures occurred in 277 children (42.7%), while 38 (5.9%) were classified as having possible abuse. These children were significantly younger than those without possible abuse (18.5 vs. 42 months; p<0.001). Among them, 34 (89.5%) had high-specificity fracture patterns, including metaphyseal corner and transphyseal lesions, whereas 4 (10.5%) had moderate-specificity patterns. No significant differences were observed according to sex or study year. Twenty-five children in the overall cohort were hospitalized. Despite fracture patterns concerning for abuse, no abuse notifications were made by pediatric emergency physicians or social services, and no child was placed under protective care. Conclusions Younger age and high-specificity skeletal injuries may increase suspicion of NAT. Interpretation should consider the injury mechanism, developmental stage, physical examination, and multidisciplinary assessment. Standardized fracture classification and coordinated child-protection pathways may facilitate earlier recognition and referral.