![]() ![]() This image displays SPNBF in the proximal third and fourth phalanges. Extensive evaluations by a rheumatologist and infectious disease physician revealed no cause of the SPNBF or fevers. Physicians were initially concerned for a rheumatic or infectious cause of the findings because of their unusual nature, lack of trauma history, and report of fevers. This child presented with swollen hands and multiple areas of SPNBF on several bones, a history of fevers, and no history of trauma. Child abusers rarely provide honest histories to physicians. The abuse finding was validated by the court, and the child was eventually adopted into a loving home. Despite this, the family’s contracted medical expert testified in family court that the findings were the result of a medication side effect. After detection of other injuries, including abdominal trauma and a burn, the mother admitted she had a boyfriend (not previously disclosed during multiple social work evaluations and medical histories) and the boy’s grandmother finally disclosed that the boyfriend would violently grab the child’s hands and twist them, causing the fractures seen in figures 12 and 13. The child’s mother eventually admitted to violently jamming a shoe onto the infant’s foot while dressing the infant. This image-like Figure 10, taken 2 weeks later than Figure 9 as part of a repeat skeletal survey-shows the subtle SPNBF on the distal tibia. Some abusive fractures are difficult to detect and require repeat radiographs over time for identification. This image, the same patient as Figure 9 but 2 weeks later, shows resolution of the cortical disruption and lucency but also displays SPNBF on both sides of the tibia. These findings are concerning for a fracture. This image shows a subtle lucency and cortical disruption (red arrow) on the distal tibia of this infant. In most cases, SPNBF is not apparent on radiograph until around 7 to 10 days after a fracture occurs. Figures 7 and 8 show new bone formation, also called subperiosteal new bone formation (SPNBF). The father grabbed the child’s right ankle and violently yanked on it, pulling the child from the mother’s arms. The child’s mother was holding the child in her arms. The classic metaphyseal lesion in the distal right tibia was caused during an incident of intimate partner violence. Therefore, the absence of SPNBF is not usually useful in dating a CML. CMLs often display no subperiosteal new bone formation (SPNBF) during their healing, or, if it is present, it is only seen for a very short time. Rare accidental causes of CMLs include mechanisms that involve yanking and twisting of the extremity, such as operative clubfoot repair and breech births. This is a classic metaphyseal fracture, also called a classic metaphyseal lesion (CML). Oblique fractures are caused by a combination of forces, often torque and bending. This is an oblique fracture of the femur. ![]() Bending loads on the radius and ulna may also be caused by a fall on an outstretched hand. An example of a bending load to the radius and ulna includes a direct impact to the diaphyseal region, such as being hit with an object across the forearm. Transverse fractures are caused by bending loads. This image shows transverse fractures of the radius and ulna. A common accidental cause of buckle fractures of the radius and ulna is a fall on an outstretched hand. ![]() Buckle fractures are caused by compressive loading. This image shows a buckle fracture of the tibial metaphysis. Any plausible history for this fracture should be compatible with torque (or twisting) being applied to the arm. When evaluating the plausibility of an injury history to explain a child’s fracture, it can be useful to first evaluate the fracture morphology. ![]()
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