Understand | diagnose | change

Whether you are looking to learn more about paediatric musculoskeletal problems, or are involved in the care of children, then PMM and PMM-Nursing will help you change your clinical practice for the better.


Non-accidental injury (NAI) is common, and potentially life-threatening.

  • NAI can present with musculoskeletal problems (such as pain, swelling or limping) and all healthcare professionals who have contact with children should be alert to the possibility of abuse. Early intervention is crucial. 
  • Where there are concerns about neglect or abuse, health care professionals must seek advice from senior clinical staff or the designated child protection lead. It is important to be familiar with local procedures and protocols for child protection.
  • Priority is to place the child in a safe environment (i.e., admit the child to the ward) and seek assessment of a paediatrician to exclude life threatening injuries, nutritional status and social circumstances, to rule out sexual abuse and ensuring safety of the child.
  • Remember that a child with chronic illness or disability may be at risk of abuse or neglect.
  • Poor attendance to appointments or adherence with treatment may be indicators to raise concerns about neglect.

Points to consider in detecting NAI:

  • Is the history variable or inconsistent with the injuries seen?
  • Was there a delay in seeking attention following an injury? 
  • In a limping child – could this be due to a fracture or soft tissue injury? Is there a history of trauma, and is it consistent with the injury? 
  • Are there multiple injuries? 
  • Are there multiple attendances to Emergency, primary care or other healthcare services? 
  • Are there signs of neglect, such as an unkempt, persistently dirty or smelly child - and especially in a child with learning difficulties or chronic illness?
  • Are the findings consistent with the developmental age of the child?
  • Certain patterns of injury are suggestive of NAI:
    • Bruising in a non-mobile child.
    • Bruising over soft tissues, multiple bruises, clusters of bruises, bruises in the shape of a hand or implement or instrument.
    • Burns in particular shapes e.g., cigarette burns, burns suggestive of forced immersion.
    • Some fractures are more suggestive of abuse than others (although none are pathognomonic) e.g., classic metaphyseal lesions (from twisting/shearing forces), posterior rib fractures (from squeezing), skull fractures, any fracture before walking age.
    •  Any fracture in a non-mobile child should raise concern about NAI.

Everyone working with children and families should be aware of, and comply with, arrangements set out by local safe guarding partners. The Royal College of Nursing gives clear statutory guidance for professionals and key roles for individual organisations and agencies to deliver effective arrangements for safeguarding. This guidance includes identifying and assessing a child or young person suffering significant harm, or at risk of significant harm, and identifying when a child or young person requires support from early help services.