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In the absence of a “gold standard” diagnostic test for child abuse, we used ranking schemes that were designed to ensure the best security of diagnosis.11 We judged studies against the highest standard (rank 1), where “a case outcome” of abuse had been made by a multi-agency child protection group or a legal panel using all available information relating to the case, a perpetrator had admitted abuse, or the abuse was witnessed.Lower ranked studies gave no details about how authors had come to a decision.

Objectives To systematically review published studies to identify the characteristics that distinguish fractures in children resulting from abuse and those not resulting from abuse, and to calculate a probability of abuse for individual fracture types. Data sources All language literature search of Medline, Medline in Process, Embase, Assia, Caredata, Child Data, CINAHL, ISI Proceedings, Sciences Citation, Social Science Citation Index, SIGLE, Scopus, TRIP, and Social Care Online for original study articles, references, textbooks, and conference abstracts until May 2007.Study selection Comparative studies of fracture at different bony sites, sustained in physical abuse and from other causes in children Skeletal fractures are diagnosed in up to a third of children who have been investigated for physical abuse.1 2 3 The fractures are often occult,1 4 and they occur in infants and toddlers who cannot give a causal explanation.Children who have been physically abused represent a small proportion of the total number of childhood fractures.Most children who sustain fractures do so from falls, motor vehicle crashes, or other non-abusive trauma.5 In addition, a small group of children are more susceptible to fractures owing to underlying conditions that contribute to bone fragility.6 All health professionals who see children should be able to recognise the characteristics of fractures resulting from abuse and initiate child protection investigations where necessary, to prevent further injury that could be fatal.7 In reality, the possibility of child abuse is often overlooked in clinical practice.8 9We systematically reviewed the published world literature to answer the question “what features differentiate fractures resulting from abuse from those sustained from other causes?We included comparative studies of children under 18 years old that described the distribution of fractures identified on radiographs, in which the fractures resulting from physical abuse were compared with those from other causes.We excluded review articles; expert opinion; consensus statements; studies of all age groups in which we could not separate data on children; studies judged to be methodologically weak owing to significant bias, confounding factors, case attrition, or incomplete ascertainment or in which the fracture pattern was the primary factor used to define abuse; and studies of outcome, management, or postmortem investigation.

Each study had two independent reviews (three if disputed) by specialist reviewers in the Welsh Child Protection Systematic Review Group, including paediatricians, paediatric radiologists, orthopaedic surgeons, and named nurses in child protection.

We critically appraised each study by using data extraction sheets, critical appraisal, and data extraction forms based on 2001 guidance from the NHS Centre for Reviews and Dissemination.10We classified included studies according to the child protection outcome decision and whether abuse had been excluded in the non-abused group (table 1).

” We aimed to identify indicators that can help clinicians to identify cases of suspected child abuse when a child presents with a fracture for which the cause cannot be confirmed.

We explore the strengths and limitations of the current evidence base and make recommendations for future research in this field.

We anticipate that this review will enable the development of evidence based clinical guidelines.

It will also contribute to the knowledge and understanding of the scientific evidence that expert medical witnesses are expected to have to support their opinion in the family and criminal courts.