Child Abuse

10.1055/b-0034-87949

Child Abuse

**Table 5.98 Child abuse: conditions that masquerade as child abuse and simulate the classic metaphyseal lesion (see Table 5.44)**
Diagnosis	Comments
Birth trauma	After low segment cesarean sections.
Iatrogenic	After orthopedic manipulations.
Osteomyelitis	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).
Leukemia	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 ).
Scurvy	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**
Specificity	Fracture
High	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
Moderate	Multiple fractures (especially bilateral) Fractures of different ages Epiphyseal separation Vertebral body fractures and subluxations Digital fractures Complex skull fractures
Low	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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