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

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.