Take a look at the x-ray above. What stands out to you? Yes, the arrows help. There are teeny tiny fractures at the ends of the bones. These fractures are called metaphyseal fractures – breaks on the metaphysis, which is the growing plate at each end of a long bone.
Let’s pretend that these are 6-year-old Bobby’s x-rays. At first glance, the injuries don’t seem significant. We are told that Bobby was running, then tripped and fell. But there is a problem with this story. The mechanism simply doesn’t match the injuries.
The size of these fractures is deceptive because they require a very high level of force: a twisting and yanking type of force. This mechanism can rip the periosteum (membrane of blood vessels and nerves that wraps around most bones) and take off a little bit of bone with it. Even though the bone fractures are small, there is actually a big tear in the periosteum and huge implications of abuse.
The story would make sense if Bobby’s extremity was caught in a washing machine, yanked very hard, and twisted. But that’s not what we are told, so this is another example where the suspicion of abuse must be investigated.
This post is part II in our “missed fractures” series. The stakes are high if abuse is missed because 30-50% of children will experience repeat abuse and 5-10% will die at the hands of their abuser. It is critical that these hallmarks of child abuse are detected in a timely manner.
Source: 2022 EM lecture by Ilene Claudius, MD
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