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Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Pediatrics 2014;133:e477-e489 INTRODUCTIONFractures are the second most common injury caused by child physical abuse; bruises are the most common injury. 1 Failure to identify an injury caused by child abuse and to intervene appropriately may place a child at risk for further abuse, with potentially permanent consequences for the child. 2-4 Physical abuse may not be considered in the physician' s differential diagnosis of childhood injury because the caregiver may have intentionally altered the history to conceal the abuse. 5 As a result, when fractures are initially evaluated, a diagnosis of child abuse may be missed. 3 In children younger than 3 years, as many as 20% of fractures caused by abuse may be misdiagnosed initially as noninflicted or as attributable to other causes. 3 In addition, fractures may be missed because radiography is performed before changes are obvious or the radiographic images are misread or misinterpreted. 2 However, incorrectly diagnosing physical abuse in a child with noninflicted fractures has serious consequences for the child and family. To identify child abuse as the cause of fractures, the physician must take into consideration the history, the age of the child, the location and type of fracture, the mechanism that causes the particular type of fracture, and the presence of other injuries while also considering other possible causes. DIFFERENTIAL DIAGNOSIS OF FRACTURES Trauma: Child Abuse Versus Noninflicted InjuriesFractures are a common childhood injury and account for between 8% and 12% of all pediatric injuries. [6][7][8] In infants and toddlers, physical FROM THE AMERICAN ACADEMY OF PEDIATRICSGuidance for the Clinician in Rendering Pediatric Care by guest on May 11, 2018 http://pediatrics.aappublications.org/ Downloaded from abuse is the cause of 12% to 20% of fractures. 9 Although unintentional fractures are much more common than fractures caused by child abuse, the physician needs to remain aware of the possibility of inflicted injury. Although some fracture types are highly suggestive of physical abuse, no pattern can exclude child abuse. 10,11 Specifically, it is important to recognize that any fracture, even fractures that are commonly noninflicted injuries, can be caused by child abuse. Certain details that can help the physician determine whether a fracture was caused by abuse rather than unintentional injury include the hist...

The number of anterior cruciate ligament (ACL) injuries reported in athletes younger than 18 years has increased over the past 2 decades. Reasons for the increasing ACL injury rate include the growing number of children and adolescents participating in organized sports, intensive sports training at an earlier age, and greater rate of diagnosis because of increased awareness and greater use of advanced medical imaging. ACL injury rates are low in young children and increase sharply during puberty, especially for girls, who have higher rates of noncontact ACL injuries than boys do in similar sports. Intrinsic risk factors for ACL injury include higher BMI, subtalar joint overpronation, generalized ligamentous laxity, and decreased neuromuscular control of knee motion. ACL injuries often require surgery and/or many months of rehabilitation and substantial time lost from school and sports participation. Unfortunately, regardless of treatment, athletes with ACL injuries are up to 10 times more likely to develop degenerative arthritis of the knee. Safe and effective surgical techniques for children and adolescents continue to evolve. Neuromuscular training can reduce risk of ACL injury in adolescent girls. This report outlines the current state of knowledge on epidemiology, diagnosis, treatment, and prevention of ACL injuries in children and adolescents.