1
Patient Context
No
Yes (OI / rickets / metabolic)
Not yet rolling
Rolling
Crawling
Cruising
Walking
Running
Unknown / not assessed
No
Yes
No
Yes
2
Fracture Type(s) Present
High Specificity for Abuse
Classic metaphyseal lesion (CML) / bucket-handle fracture
Corner/bucket-handle appearance at metaphysis. High specificity for inflicted injury in infants.
Posterior rib fracture
Caused by forceful anteroposterior thoracic compression. Generally considered a hallmark of NAI in infants.
Spinous process fracture
Rare; high association with inflicted injury. Often identified on skeletal survey.
Scapular / sternal fracture
Require significant force; rare accidental causes in infants.
Moderate Specificity â Context Dependent
Multiple fractures at different stages of healing
Implies repeated injury episodes. Requires correlation with history.
Bilateral long bone fractures
Bilateral symmetrical injuries without plausible accidental mechanism.
Epiphyseal separation
Traction/twisting mechanism. Requires significant force in young children.
Femoral fracture in a non-ambulant child
A femoral fracture without a plausible mechanism in a pre-walking child is concerning.
Multiple rib fractures (lateral/anterior)
Less specific than posterior ribs, but multiple rib fractures without major trauma are suspicious.
Lower Specificity â Highly Context Dependent
Skull fracture
Can occur accidentally. Complex, bilateral, or depressed pattern raises concern. Correlate with mechanism.
Spiral / transverse long bone fracture
Toddler's fracture is a common accidental injury. Assess mechanism and developmental stage carefully.
Clavicle fracture
Common accidental injury; rarely alone raises concern. Context important.
3
History Assessment
History is absent, vague, or no explanation given for the fracture
History has changed between accounts or between different carers
Described mechanism is biomechanically implausible for the fracture type
Mechanism is inconsistent with the child's developmental stage (e.g. "fell off sofa" in a 2-month-old)
Unexplained delay in seeking medical attention
Different accounts given to different professionals (ED, GP, ambulance)
Injury attributed to another child or the child themselves in an implausible way
4
Associated Injuries & Features
Bruising in a non-mobile infant ("those who don't cruise, don't bruise")
Retinal haemorrhages present or suspected
Intracranial injury / subdural haematoma
Unexplained intra-abdominal injury
Unexplained thermal injury (scalds, burns)
Evidence of older fractures on imaging (different stages of healing)
Prior child protection concerns / previous ED attendances for injuries
ðĐ Active Flags
â Recommended Actions
âïļ Important: This tool supports clinical decision-making â it does not diagnose non-accidental injury.
High-specificity fractures (e.g. CML, posterior ribs) can rarely occur in osteogenesis imperfecta, metabolic bone disease, and birth trauma â these conditions must be considered and excluded.
All concerns must be escalated to a senior paediatrician and managed through your local safeguarding / MASH pathway. Document your reasoning fully in the clinical notes.