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Pediatrics
Diagnosis
Musculoskeletal
Trauma: General
Child Abuse, Metaphyseal Fracture
Child Abuse, Metaphyseal Fracture
Michael R. Aquino, MD, MHSc
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KEY FACTS

  • Terminology

    • Imaging

      • Pathology

        • Clinical Issues

          TERMINOLOGY

          • Synonyms

            • Nonaccidental trauma (NAT), battered child syndrome
            • Metaphyseal corner fracture, classic metaphyseal lesion (CML), bucket-handle fracture

          • Definitions

            • Fracture of infants that extends though subphyseal metaphysis & undercuts subperiosteal bone collar (SPBC) peripherally

          IMAGING

          • General Features

            • Radiographic Findings

              • CT Findings

                • MR Findings

                  • Ultrasonographic Findings

                    • Nuclear Medicine Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            CLINICAL ISSUES

                            • Presentation

                              • Demographics

                                • Natural History & Prognosis

                                  • Treatment

                                    DIAGNOSTIC CHECKLIST

                                    • Reporting Tips

                                      Selected References

                                      1. Karmazyn B et al: Accuracy of ultrasound in the diagnosis of classic metaphyseal lesions using radiographs as the gold standard. Pediatr Radiol. 50(8):1123-30, 2020
                                      2. Karmazyn B et al: Establishing signs for acute and healing phases of distal tibial classic metaphyseal lesions. Pediatr Radiol. 50(5):715-25, 2020
                                      3. Marine MB et al: Ultrasound findings in classic metaphyseal lesions: emphasis on the metaphyseal bone collar and zone of provisional calcification. Pediatr Radiol. 49(7):913-21, 2019
                                      4. Tsai A et al: Subperiosteal new bone formation with the distal tibial classic metaphyseal lesion: prevalence on radiographic skeletal surveys. Pediatr Radiol. 49(4):551-8, 2019
                                      5. Tsai A et al: The distal tibial classic metaphyseal lesion: medial versus lateral cortical injury. Pediatr Radiol. 48(7):973-8, 2018
                                      6. Tsai A et al: Biomechanics of the classic metaphyseal lesion: finite element analysis. Pediatr Radiol. 47(12):1622-30, 2017
                                      7. Servaes S et al: The etiology and significance of fractures in infants and young children: a critical multidisciplinary review. Pediatr Radiol. 46(5):591-600, 2016
                                      8. Thackeray JD et al: The classic metaphyseal lesion and traumatic injury. Pediatr Radiol. 46(8):1128-33, 2016
                                      9. Barber I et al: The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatr Radiol. 45(1):69-80, 2015
                                      10. Kleinman, PK. Diagnostic imaging of child abuse, 3rd edition. Cambridge University Press, 2015
                                      11. Perez-Rossello JM et al: Absence of rickets in infants with fatal abusive head trauma and classic metaphyseal lesions. Radiology. 275(3):810-21, 2015
                                      12. Brown SD et al: SPR Child Abuse Committee Response regarding classic metaphyseal lesion. AJR Am J Roentgenol. 203(2):W232, 2014
                                      13. Quigley AJ et al: Skeletal survey normal variants, artefacts and commonly misinterpreted findings not to be confused with non-accidental injury. Pediatr Radiol. 44(1):82-93; quiz 79-81, 2014
                                      14. Tsai A et al: High-resolution CT with histopathological correlates of the classic metaphyseal lesion of infant abuse. Pediatr Radiol. 44(2):124-40, 2014
                                      15. U.S. Department of Health & Human Services, Administration for Children & Families, Administration on Children, Youth & Families, Children’s Bureau. (2016). Child maltreatment 2014
                                      16. Dwek JR: The radiographic approach to child abuse. Clin Orthop Relat Res. 469(3):776-89, 2011
                                      17. Kleinman PK et al: Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol. 197(4):1005-8, 2011
                                      18. Chapman T et al: Fractures in infants and toddlers with rickets. Pediatr Radiol. 2010 Jul;40(7):1184-9. Epub 2009 Dec 9. Erratum in: Pediatr Radiol. 40(7):1308, 2010
                                      19. Drubach LA et al: Skeletal trauma in child abuse: detection with 18F-NaF PET. Radiology. 255(1):173-81, 2010
                                      20. Perez-Rossello JM et al: Whole-body MRI in suspected infant abuse. AJR Am J Roentgenol. 195(3):744-50, 2010
                                      21. Harlan SR et al: Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed? Pediatr Radiol. 39(9):962-8, 2009
                                      22. Hobbs CJ et al: Nonaccidental trauma: clinical aspects and epidemiology of child abuse. Pediatr Radiol. 39(5):457-60, 2009
                                      23. Peters ML et al: The presence of bruising associated with fractures. Arch Pediatr Adolesc Med. 162(9):877-81, 2008
                                      24. Slovis TL et al: Evaluating the data concerning vitamin D insufficiency/deficiency and child abuse. Pediatr Radiol. 38(11):1221-4, 2008
                                      25. Arkader A et al: Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age. J Pediatr Orthop. 27(7):751-3, 2007
                                      26. Lonergan GJ et al: From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 23(4):811-45, 2003
                                      27. Mandelstam SA et al: Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child. 88(5):387-90; discussion 387-90, 2003
                                      28. Boal DK: Metaphyseal fractures. Pediatr Radiol. 32(7):538-9, 2002
                                      29. Kleinman PK et al: A regional approach to the classic metaphyseal lesion in abused infants: the distal femur. AJR Am J Roentgenol. 170(1):43-7, 1998
                                      30. Kleinman PK et al: A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. AJR Am J Roentgenol. 166(5):1207-12, 1996
                                      31. Kleinman PK et al: A regional approach to the classic metaphyseal lesion in abused infants: the proximal humerus. AJR Am J Roentgenol. 167(6):1399-403, 1996
                                      32. Kleinman PK et al: A regional approach to the classic metaphyseal lesion in abused infants: the proximal tibia. AJR Am J Roentgenol. 166(2):421-6, 1996
                                      33. Kleinman PK et al: Follow-up skeletal surveys in suspected child abuse. AJR Am J Roentgenol. 167(4):893-6, 1996
                                      34. Kleinman PK et al: Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants. AJR Am J Roentgenol. 165(3):647-50, 1995
                                      35. Kleinman PK et al: Relationship of the subperiosteal bone collar to metaphyseal lesions in abused infants. J Bone Joint Surg Am. 77(10):1471-6, 1995
                                      36. Kemp AM et al: Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008 Oct 2;337:a1518. doi: 10. PubMed Central PMCID: PMC2563260, 1136
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Terminology

                                        • Imaging

                                          • Pathology

                                            • Clinical Issues

                                              TERMINOLOGY

                                              • Synonyms

                                                • Nonaccidental trauma (NAT), battered child syndrome
                                                • Metaphyseal corner fracture, classic metaphyseal lesion (CML), bucket-handle fracture

                                              • Definitions

                                                • Fracture of infants that extends though subphyseal metaphysis & undercuts subperiosteal bone collar (SPBC) peripherally

                                              IMAGING

                                              • General Features

                                                • Radiographic Findings

                                                  • CT Findings

                                                    • MR Findings

                                                      • Ultrasonographic Findings

                                                        • Nuclear Medicine Findings

                                                          • Imaging Recommendations

                                                            DIFFERENTIAL DIAGNOSIS

                                                              PATHOLOGY

                                                              • General Features

                                                                CLINICAL ISSUES

                                                                • Presentation

                                                                  • Demographics

                                                                    • Natural History & Prognosis

                                                                      • Treatment

                                                                        DIAGNOSTIC CHECKLIST

                                                                        • Reporting Tips

                                                                          Selected References

                                                                          1. Karmazyn B et al: Accuracy of ultrasound in the diagnosis of classic metaphyseal lesions using radiographs as the gold standard. Pediatr Radiol. 50(8):1123-30, 2020
                                                                          2. Karmazyn B et al: Establishing signs for acute and healing phases of distal tibial classic metaphyseal lesions. Pediatr Radiol. 50(5):715-25, 2020
                                                                          3. Marine MB et al: Ultrasound findings in classic metaphyseal lesions: emphasis on the metaphyseal bone collar and zone of provisional calcification. Pediatr Radiol. 49(7):913-21, 2019
                                                                          4. Tsai A et al: Subperiosteal new bone formation with the distal tibial classic metaphyseal lesion: prevalence on radiographic skeletal surveys. Pediatr Radiol. 49(4):551-8, 2019
                                                                          5. Tsai A et al: The distal tibial classic metaphyseal lesion: medial versus lateral cortical injury. Pediatr Radiol. 48(7):973-8, 2018
                                                                          6. Tsai A et al: Biomechanics of the classic metaphyseal lesion: finite element analysis. Pediatr Radiol. 47(12):1622-30, 2017
                                                                          7. Servaes S et al: The etiology and significance of fractures in infants and young children: a critical multidisciplinary review. Pediatr Radiol. 46(5):591-600, 2016
                                                                          8. Thackeray JD et al: The classic metaphyseal lesion and traumatic injury. Pediatr Radiol. 46(8):1128-33, 2016
                                                                          9. Barber I et al: The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatr Radiol. 45(1):69-80, 2015
                                                                          10. Kleinman, PK. Diagnostic imaging of child abuse, 3rd edition. Cambridge University Press, 2015
                                                                          11. Perez-Rossello JM et al: Absence of rickets in infants with fatal abusive head trauma and classic metaphyseal lesions. Radiology. 275(3):810-21, 2015
                                                                          12. Brown SD et al: SPR Child Abuse Committee Response regarding classic metaphyseal lesion. AJR Am J Roentgenol. 203(2):W232, 2014
                                                                          13. Quigley AJ et al: Skeletal survey normal variants, artefacts and commonly misinterpreted findings not to be confused with non-accidental injury. Pediatr Radiol. 44(1):82-93; quiz 79-81, 2014
                                                                          14. Tsai A et al: High-resolution CT with histopathological correlates of the classic metaphyseal lesion of infant abuse. Pediatr Radiol. 44(2):124-40, 2014
                                                                          15. U.S. Department of Health & Human Services, Administration for Children & Families, Administration on Children, Youth & Families, Children’s Bureau. (2016). Child maltreatment 2014
                                                                          16. Dwek JR: The radiographic approach to child abuse. Clin Orthop Relat Res. 469(3):776-89, 2011
                                                                          17. Kleinman PK et al: Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol. 197(4):1005-8, 2011
                                                                          18. Chapman T et al: Fractures in infants and toddlers with rickets. Pediatr Radiol. 2010 Jul;40(7):1184-9. Epub 2009 Dec 9. Erratum in: Pediatr Radiol. 40(7):1308, 2010
                                                                          19. Drubach LA et al: Skeletal trauma in child abuse: detection with 18F-NaF PET. Radiology. 255(1):173-81, 2010
                                                                          20. Perez-Rossello JM et al: Whole-body MRI in suspected infant abuse. AJR Am J Roentgenol. 195(3):744-50, 2010
                                                                          21. Harlan SR et al: Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed? Pediatr Radiol. 39(9):962-8, 2009
                                                                          22. Hobbs CJ et al: Nonaccidental trauma: clinical aspects and epidemiology of child abuse. Pediatr Radiol. 39(5):457-60, 2009
                                                                          23. Peters ML et al: The presence of bruising associated with fractures. Arch Pediatr Adolesc Med. 162(9):877-81, 2008
                                                                          24. Slovis TL et al: Evaluating the data concerning vitamin D insufficiency/deficiency and child abuse. Pediatr Radiol. 38(11):1221-4, 2008
                                                                          25. Arkader A et al: Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age. J Pediatr Orthop. 27(7):751-3, 2007
                                                                          26. Lonergan GJ et al: From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 23(4):811-45, 2003
                                                                          27. Mandelstam SA et al: Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child. 88(5):387-90; discussion 387-90, 2003
                                                                          28. Boal DK: Metaphyseal fractures. Pediatr Radiol. 32(7):538-9, 2002
                                                                          29. Kleinman PK et al: A regional approach to the classic metaphyseal lesion in abused infants: the distal femur. AJR Am J Roentgenol. 170(1):43-7, 1998
                                                                          30. Kleinman PK et al: A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. AJR Am J Roentgenol. 166(5):1207-12, 1996
                                                                          31. Kleinman PK et al: A regional approach to the classic metaphyseal lesion in abused infants: the proximal humerus. AJR Am J Roentgenol. 167(6):1399-403, 1996
                                                                          32. Kleinman PK et al: A regional approach to the classic metaphyseal lesion in abused infants: the proximal tibia. AJR Am J Roentgenol. 166(2):421-6, 1996
                                                                          33. Kleinman PK et al: Follow-up skeletal surveys in suspected child abuse. AJR Am J Roentgenol. 167(4):893-6, 1996
                                                                          34. Kleinman PK et al: Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants. AJR Am J Roentgenol. 165(3):647-50, 1995
                                                                          35. Kleinman PK et al: Relationship of the subperiosteal bone collar to metaphyseal lesions in abused infants. J Bone Joint Surg Am. 77(10):1471-6, 1995
                                                                          36. Kemp AM et al: Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008 Oct 2;337:a1518. doi: 10. PubMed Central PMCID: PMC2563260, 1136