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Child Abuse, Metaphyseal Fractures


KEY FACTS

Terminology

  • Classic metaphyseal lesion (CML) or metaphyseal corner fracture: Transverse fracture of subphyseal metaphysis that undercuts subperiosteal bone collar peripherally

    • Fracture of infants with high specificity for child abuse

Imaging

  • Most common at distal femur, proximal & distal tibia

  • Radiographic appearance

    • Acute fractures subtle, often difficult to identify initially

      • –

        Triangular fragment at metaphyseal corner when x-ray beam perpendicular to bone long axis

      • –

        Bucket-handle fragment adjacent to metaphysis when x-ray beam angled caudal or cranial relative to physis

    • Healing fractures more conspicuous

      • –

        Subperiosteal new bone formation & callus require 7-14 days to appear radiographically

Pathology

  • Due to tensile & torsional forces from twisting or pulling extremity or from acceleration/deceleration of shaking

    • 95% of cases with CML have ≥ 1 additional injury

  • No established evidence that rickets/metabolic bone disease can cause CML

Clinical Issues

  • Wide range of clinical presentations for nonaccidental trauma (NAT)

    • Injury inconsistent with history or stage of development

    • Multiple injuries in various stages of healing

    • Bruising in nonmobile infant

  • Initial skeletal survey obtained for

    • < 2 years old with suspicion of NAT

    • < 5 years old with suspicious fracture

    • Concern for NAT in any child unable to communicate

  • Obtain follow-up skeletal survey in 2 weeks: Healing increases fracture conspicuity

AP radiograph in a 1-month-old girl shows a typical metaphyseal corner fracture at the distal femoral metaphysis
with a bucket- handle appearance of a proximal tibial metaphyseal fracture
.

AP (left) & lateral (right) radiographs of the right lower leg in a 6 month old with bruising show lucent irregularities of the subphyseal tibial metaphyses proximally
& distally
. A corner fragment is best appreciated anteriorly at the distal tibia on the lateral view.

AP radiographs of the right humerus in the same patient at the time of presentation (left) & 2 weeks later (right) show an evolving acromion fracture
(which has a high specificity for nonaccidental trauma). Initial image shows minimal proximal humeral metaphyseal abnormality
that becomes much more conspicuous on the follow-up study with abundant periosteal reaction
.

AP radiographs in the same patient (at presentation) show bilateral corner fractures of the distal radial metaphyses
.

TERMINOLOGY

Synonyms

  • Nonaccidental trauma (NAT), battered child syndrome

  • Metaphyseal corner fracture, classic metaphyseal lesion (CML), bucket-handle fracture

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