Child Abuse


Child Abuse

Table 5.98 Child abuse: conditions that masquerade as child abuse and simulate the classic metaphyseal lesion (see Table 5.44)



Birth trauma

After low segment cesarean sections.


After orthopedic manipulations.


Osteomyelitis has a predilection for the metaphysis in infants. Although systemic signs and symptoms of infection may be lacking in infants and multiple sites of osteomyelitis and different stages of healing may simulate child abuse, the metaphyseal erosions in osteomyelitis tend to be less well-defined than classic metaphyseal lesions (CMLs; see Table 5.43 ).

Rickets and metabolic bone disease

Fig. 5.180

Controversy exists as to whether or not osseous fragments resembling CMLs are always accompanied by more obvious changes of rickets such as metaphyseal irregularity and physeal widening.70,71 Laboratory findings may also help support a diagnosis of rickets.

Bone dysplasias

Skeletal survey will reveal other abnormalities associated with the given skeletal dysplasia. DD: osteogenesis imperfecta, metaphyseal chondrodysplasia (Schmid type), and spondylometaphyseal dysplasia (corner fracture type).


Bone demineralization, osteolytic lesions, and subperiosteal new bone formation. Radiolucent bands at the metaphyses. Imaging findings may be due to a combination of nutritional disturbance and leukemic invasion (see Table 5.43 ).


Subperiosteal hemorrhage and metaphyseal and epiphyseal changes. Characteristic findings of scurvy may help to distinguish from child abuse (see Table 5.43 ).

Vitamin A intoxication

Subperiosteal new bone formation predominantly in the tubular bones.

Lower extremity paralysis

Routine handling of infants with paralysis may cause fractures.

Infantile cortical hyperostosis (Caffey disease)

Subperiosteal new bone formation and cortical thickening. Preference for the mandible, clavicle, and ulna.

Menkes syndrome (kinky hair disease)

Rare genetic disorder resulting in defective gastrointestinal absorption of copper. Metaphysis of the long bones have spurs ± fractures. Subperiosteal new bone formation and bone demineralization. Tortuous and irregular cerebral and abdominal arteries.

Congenital indifference/insensitivity to pain

Lack of sensation of pain may lead to a delay in diagnosis of both minor and major trauma. Imaging may show metaphyseal injuries, subperiosteal hemorrhage, fractures, and epiphyseal separations in various stages of healing during infancy. Charcot-type joints manifest later in childhood.

Fig. 5.180 Rickets and metabolic bone disease. Metaphyseal irregularity simulating a metaphyseal corner fracture (arrow) in a 3-year-old girl with resorptive metabolic bone disease of unclear etiology.

Table 5.99 Child abuse: specificity of fracture locations




Classic metaphyseal lesion

Fig. 5.74, p. 545

Fig. 5.75, p. 545

Rib fractures

Fig. 5.181

Scapular fractures

Spinous process fractures

Sternal fractures


Multiple fractures (especially bilateral)

Fractures of different ages

Epiphyseal separation

Vertebral body fractures and subluxations

Digital fractures

Complex skull fractures


Subperiosteal new bone formation

Clavicular fractures

Long bone shaft fractures Linear skull fractures

Table 5.99 reproduced with permission from Kleinman PK. Diagnostic imaging of child abuse. 2nd ed. St. Louis: Mosby, 1989.

Fig. 5.181 Healing posterior rib fractures (arrow) in child abuse.


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