Source:Grayev AM, Boal DKB, Wallach DM, et al. Metaphyseal fractures mimicking abuse during treatment for clubfoot.
Pediatr Radiol.
2001
;
31
:
559
–563.

The classic metaphyseal injury of child abuse is described as a corner or “buckethandle” fracture which occurs as a result of indirect shearing forces when the extremity is pulled, pushed, twisted, or shaken. The injury is considered specific for child abuse. However, positioning techniques undertaken during manipulation for serial castings of clubfoot in children include pushing and twisting with forced eversion and dorsiflexion to overcome the equinovarus deformity. All techniques for non-surgical management of clubfoot include stretching and manipulation of the lower extremity. Serial casting is then initiated. Dorsiflexion and stretching of the tendocalcaneus and calf muscle groups to correct the equinus is begun after correction of the hindfoot varus and forefoot adductus. Children with underlying neuromuscular abnormalities have a more rigid clubfoot and may be more predisposed to injury.

This study, from the Milton Hershey Medical Center, Hershey, PA, identified 8 infants with clubfoot deformity, ranging in age from 1–4 months at the time of diagnosis. Seven had bilateral clubfoot deformity and 1 had unilateral deformity. All were treated with serial casting. Seven of the infants had distal tibial and fibular metaphyseal fractures with angular deformity and periosteal reaction identified on routine monitoring radiographs. One infant also had multiple rib fractures thought to be the result of child abuse. Three of the 8 infants had an underlying neuromuscular abnormality. A total of 14 tibial bony injuries were documented in the patient group. The authors conclude that while metaphyseal fractures are highly specific for abuse, they may also be present in infants undergoing serial casting for treatment of equinovarus deformity.

It is apparent that while metaphyseal fractures in infancy are usually indicative of child abuse, the fractures result from specific manipulations of the extremity, and the presence of a corner or “buckethandle” fracture alone does not establish that those manipulations were the result of abuse. It has been suggested that metaphyseal fractures of the extremities may be secondary to a true accidental injury or birth trauma.1 Metabolic disorders and some skeletal dysplasias mimic the fractures of non-accidental trauma in appearance but occur in multiple locations, and some normal metaphyseal variants including tibial cortical irregularity and spurs which occur at the knee are recognized but do not affect the distal tibia and fibula.2,3 Another study identified fracture as a complication of treatment of clubfoot.4 Those injuries included distal tibial and fibular compression fractures, distal tibial metaphyseal spur, torus fractures of the distal tibial metaphysis, and fracture of the distal fibula. All fractures healed without complication.

While we must remain alert for occult findings of child abuse, it is also important to be aware of the misleading fractures resulting from manipulation of the lower extremity in an infant undergoing treatment for clubfoot.

While it is nice to know that there are other diagnostic possibilities that are associated with the classic metaphyseal injury usually...

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