Abuse should be considered if:

• multiple fractures
• rib fractures (7 in 10 NAI)
• femoral fracture (see below)
• Under 3 with humeral fracture (1 in 2 NAI)
• Mid shaft humeral fracture more frequently NAI, supracondylar less frequently
• Infant/toddler skull fracture (1 in 3 NAI).  Type and location not helpful

The Welsh Child Protection Systematic Review Group reviewed femoral fractures in non-accidental injury (NAI). Findings were:

• Fractures in the abuse group occurred predominantly in children less than one year of age
• Femoral fractures under one year of age are significantly associated with abuse
• A third of isolated femoral fractures under three years of age were abusive
• Abusive femoral fractures occur predominantly in infants (evidence level IIb) [1]
• Significantly more abusive femoral fractures arise in children who are not yet walking (evidence level IIb) [1]
• Mid-shaft fracture is the commonest fracture in both abuse and non-abuse groups (analysed for all age groups)(evidence level IIa) [1]
• Under fifteen months of age a spiral fracture is the commonest abusive femoral fracture p=0.05 (evidence level IIb) [1]

Rib fractures with callus are at least 2 weeks old.  Other than that, unable to date.

Systematic reviews of various NAI issues at https://childprotection.rcpch.ac.uk/child-protection-evidence/