Fracture patterns in suspected non-accidental injury across neurodevelopmental milestones: A systematic review and
Daniela Alessia Marletta1, Gabriele Giuca1, Danilo Leonetti1
1Section of Orthopaedics and Traumatology, Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, 98122, Messina, ME, Italy.
Background:
Determining whether a pediatric fracture is congruent with the reported mechanism is challenging even with age-based guidance. We synthesize fracture evidence by neurodevelopmental milestones to organize plausibility judgments that augment, not replace, multidisciplinary abuse evaluations.
Objective:
To synthesize evidence linking fracture patterns to developmental milestones in children ≤36 months evaluated for suspected non-accidental injury (NAI) and to propose a milestone-anchored, evidence-informed plausibility framework.
Methods:
Following PRISMA 2020, we searched PubMed, Embase and Scopus from inception to 19 August 2025. Two reviewers independently screened/extracted data and assessed risk of bias (Newcastle-Ottawa Scale for cohort/case-control).
Protocol Registration:
PROSPERO CRD420251120765. Eligibility required data linking fracture type/location to age or explicit motor milestones (e.g., pre-rolling, crawling and walking). Quantitative synthesis was restricted to within-cohort strata: we calculated stratum-specific odds ratios, a Mantel-Haenszel within-cohort stratified pooled estimate across long-bone strata and (where informative) Bayesian Beta-Binomial posterior summaries; cross-cohort pooling was avoided because of cohort overlap and heterogeneous abuse determination.
Results:
Across primary studies, non-ambulatory infants with long-bone (diaphyseal) fractures had markedly higher odds of abuse than ambulatory toddlers (within-cohort pooled OR 15.12, 95 % CI 2.88-79.36). Infants <12 months with rib fractures had abuse prevalences 67-82 % when motor-vehicle crashes and bone disease were included and ~91 % when excluded; rib fracture location was not independently associated with abuse likelihood. Classic metaphyseal lesions (CMLs) are highly suggestive, though not pathognomonic, of abuse in non-ambulatory infants. In one cohort, multiple fractures were present in 84 % (16/19) of children reported as suspected abuse. Collectively, findings support a milestone-aware approach to plausibility.
Conclusions:
Fracture patterns correlate with developmental capabilities. Organized by milestones, these data inform, but do not determine, abuse evaluations and should be integrated with history, examination, guideline-concordant imaging, differential for bone fragility when indicated and multidisciplinary assessment.
