Distinguishing child abuse fractures from rickets
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The keystone of distinguishing suspected child abuse on radiographs from manifestations of rickets, including healing rickets, is looking at bones other than that bone suspected of rickets, as well as carefully perusing the bone under suspicion. Understanding the metaphyseal collar and the zone of provisional calcification as part of the normal, non-rachitic, tubular bone metaphyses should help distinguish between rickets and changes related to fracture.
As was strongly proclaimed by an editorial in this journal , a great problem exists from those medical professionals who, in testimony and in print, deny abuse as a cause for radiologic abnormalities widely accepted as suggestive of child abuse.
Child abuse vs. rickets
Child abuse denialists often claim that radiographic findings generally recognized by pediatric radiologists as having high specificity for abusive trauma are instead a consequence of rickets, including healing rickets . In particular, bucket handle fractures (classic metaphyseal lesions) at metaphyses are declared to be identical in pattern to healing rickets . I demonstrate by reviewing the details of these different patterns that this is an incorrect declaration. Additionally, concavity of the distal ulna metaphysis alone is not a sign of rickets . Rickets is radiologically distinct from classic metaphyseal fractures (see also ).
Other comments on rickets
Most children with most types of rickets manifest findings of secondary hyperparathyroidism as well . Findings of hyperparathyroidism include loss of lamina dura around unerupted teeth, washing out (increased porosity) of tubular bone cortices and coarsened trabeculae within tubular bones. The lack of these findings decreases the likelihood of rickets being present.
If there is suspicion of rickets at the end of a tubular bone one must carefully evaluate all of the imaged bones. If the metaphyseal collars of Laval-Jeantet are intact and if the zones of provisional calcification are calcified, then the child does not have rickets. Rickets is systemic and symmetrical; classic metaphyseal fractures are not. Patterns of fracture considered to be of high specificity for child abuse are distinctly different from healing rickets and this should not be denied.
Based on a talk at the European Society of Paediatric Radiology in Davos, Switzerland, on June 1, 2017.
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Conflicts of interest
- 5.Laval-Jeantet M, Balmain N, Juster M et al (1968) Les rapports de la virole périchondrale et du cartilage en croissance normale et pathologique [Relations of the perichondral ring to the cartilage in normal and in pathological growth]. Ann Radiol 11:327–335Google Scholar