by Dr Noreen Norfaraheen Lee Abdullah MD (UKM), MMed Radiology (UKM), AM(Mal)

Answer to Case Of the Month 
Recent metaphyseal bucket handle fracture (frontal view) and corner fractures (Lateral view) of the distal right tibia (Non-accidental injury must be suspect)

Discussion of Findings
Non-accidental injury is also known as child abuse or battered baby syndrome. There is intentional wounding of the child which may be in the form of physical, sexual or emotional abuse. Skeletal abuse usually occurs in infants (less than 1 year old) and toddlers (1 to 5 years old). Most of the time the injury manifest as fractures.

Skeletal injuries that are specific for abuse are:

• posterior rib fractures

• metaphyseal corner fractures

• fractures in the scapula, spinous process and sternum

• multiple fractures (especially bilateral)

• fractures of different ages

• epiphyseal separations (Salter Harris fractures)

• vertebral body fractures / subluxations)

• hand and foot fractures especially metacarpals and metatarsals

• complex skull fractures

• clavicle fractures

The metaphyseal fracture or bucket handle fracture is pathognomonic for child abuse. These fractures occur due to pulling and twisting of the affected limb. It is common in the long bones such as humerus, femur and tibia. It is believed that these fractures occur in the most immature part of the metaphysis, which is the zone of provisional calcification of the primary spongiosa. The fracture fragment consists of two invisible layers i.e. the physis and the epiphysis and the thin calcified metaphyseal layer of the primary spongiosa.

The corner fracture is the edge of the bucket handle fracture. Note that it is not a chip or avulsion fracture. When the metaphyseal fragment is radiographed tangentially it looks like a flat disc of bone separated from the rest of the metaphysis by a lucent fracture line. If the joint is slightly flexed or the projection not exactly at right angles to the fracture line, the metaphyseal fragment appear tipped and resemble a crescent or bucket handle fracture. The corner fracture is the peripheral thicker edge of the entire metaphyseal fragment (bucket handle) and that is why it is best appreciated on the lateral view.

It is important in our practice to look out for the above-mentioned features when reviewing children’s radiographs. When any one of the features is seen in one radiograph, a skeletal survey is mandatory.

It consists of several radiographs namely:

• Anteroposterior / frontal view of each upper extremity

• Posteroanterior view of the hands

• Anteroposterior / frontal view of each lower extremity

• Anteroposterior of the feet

• Anteroposterior view of the chest

• Anteroposterior and lateral view of the spine

• Anteroposterior and lateral view of the skull

• Anteroposterior abdomen and pelvis

A babygram is not acceptable. This is because the skeletal injuries resulting from non-accidental injury may be subtle and escape detection in the babygram. Moreover, a babygram cannot provide the level of detail required to present a convincing argument in court to prove that child abuse had occurred.
 

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Last Updated:
Tuesday, 04 January 2005