A witnessed case of a classic metaphyseal fracture caused during IV line placement in a child: Insight into mechanism of injury

doi:10.1016/j.jflm.2015.07.005

Journal of Forensic and Legal Medicine

Volume 35, October 2015, Pages 51-53

https://doi.org/10.1016/j.jflm.2015.07.005 Get rights and content

Highlights

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We report a witnessed occurrence of a classic metaphyseal fracture, or “lesion” (CML).
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Prior x-rays of the involved bone identified normal ossification and structure.
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An evaluation for boney metabolic conditions was negative.
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The traumatic origin of CMLs is supported.
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The mechanics that may cause a CML are identified.

Abstract

Recent publications argue that classic metaphyseal fractures are caused by rickets as opposed to trauma. Previous case reports of accidental traumatic classic metaphyseal fractures have been discounted due to lack of identification of the fracture at the time of the traumatic event, and lack of an evaluation for boney metabolic disorders. We report a case of a 20 day old male with a diagnosis of congenital vertical talus who sustained a classic metaphyseal fracture of the distal tibia during manipulation in preparation for intravenous line placement. The mechanics of the event causing the classic metaphyseal fracture were witnessed and accompanied by an audible “pop”. Prior x-rays of the tibia demonstrate normal osseous morphology, and an evaluation for boney metabolic disorders was normal. This case identifies a traumatic classic metaphyseal fracture and provides insight into the types of forces necessary to cause such a fracture.

Introduction

Classic metaphyseal fractures (also termed, “classic metaphyseal lesions”, or CMLs) are highly specific for nonaccidental trauma. They frequently occur at the distal femur, proximal tibia, distal tibia, and proximal humerus. Specific postulated types of forces include torsion and traction applied as an infant is twisted or pulled by an extremity.¹ However, recent publications have questioned the traumatic origins of CMLs, and postulated that they are actually healing metabolic bone disease, most frequently rickets.² Specific assertions used to support a non-traumatic etiology for CMLs include that previously reported cases of accidental traumatic CMLs were not evaluated for metabolic bone disease, and that proposed accidental traumatic causes of the reported CMLs were not exactly temporally linked to the discovery of the CML.

We report an infant with a CML occurring due to foot manipulation in preparation for an attempted peripheral intravenous (PIV) line placement. The event was independently witnessed, including an audible “pop” at the time of the fracture, with a detailed description of the mechanics of the forces causing the fracture, specific, immediate symptoms and an evaluation for bone fragility, including vitamin D deficient rickets. The infant in this case had congenital vertical talus with foot contractures, possibly resulting in a decreased amount of force necessary to cause a traumatic CML; however, the nature of the traumatic forces was consistent with those previously hypothesized to cause CMLs.

Section snippets

Case report

A thirteen day old infant was referred to the orthopedics clinic in our pediatric tertiary medical center for evaluation of congenital vertical talus. Other than the vertical talus, the child was previously well, being the product of normal, spontaneous vaginal delivery after a 36 week gestation pregnancy in a healthy mother. The child required some monitoring for temperature instability and hypoglycemia after birth, but this resolved quickly and he was discharged home on day of life two. He

Discussion

CMLs have been extensively studied and long associated with abusive trauma. Though a pathological description of the CML is beyond the scope of this report and available elsewhere, the core injury is a “transmetaphyseal disruption of the trabeculae of the primary spongiosa” occurring when torsional and traction forces are applied to an infant, such as twisting and/or pulling an extremity.¹ However, specific detailed descriptions of known, witnessed incidents causing CMLs are lacking, making

Conflict of interest

None.

Funding

None declared.

Ethical approval

None declared.

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Classic metaphyseal lesion following external cephalic version and cesarean section
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There are more references available in the full text version of this article.

Cited by (15)

Iatrogenic Flexion-Related Classic Metaphyseal Lesion of the Distal Tibia: Three Cases
2023, Journal of Emergency Medicine
Classic metaphyseal lesions (CMLs) should raise concern for nonaccidental trauma. However, iatrogenic causes for CMLs have increasingly been described and warrant close consideration. Increasing the clinical understanding of CML mechanics and their relation to often routine medical procedures will enhance provider awareness and expand the differential diagnosis when these otherwise highly concerning injuries are identified.
We describe three clinical cases where suspected iatrogenic dorsiflexion or plantar flexion resulted in an isolated distal tibia CML. Respectively, we present heel-stick testing and i.v. line placement as clinical correlates of these two mechanisms. Although prior reports have aimed to describe iatrogenic CML etiologies, they have not focused on dorsiflexion or plantar flexion as predominant mechanisms of injury.
Emergency physicians are critical to the surveillance and identification of nonaccidental trauma. Given that children oftentimes present to the emergency department with subtle yet concerning signs of maltreatment, an emergency physician must be aware of the potential causes of injury as well as the recommended response. Although avoiding missed cases of abuse and improving the detection of injuries is crucial for child health and well-being, failing to consider or recognize alternative explanations could also have serious implications for a child and their caregivers.
Safeguarding children in trauma and orthopaedics
2022, Paediatrics and Child Health (United Kingdom)
Citation Excerpt :
Several reports in the literature document birth injury as the cause of CMLs; even rib fractures after birth injury have been described.67 CMLs have also been described after physical therapy for club foot treatment or after cannula insertion and it should be documented if the child has undergone such therapy.68–70 Family history or personal history of recurrent fractures and fractures after minor injury, should prompt consultation with a specialist paediatric endocrinologist or a geneticist to exclude metabolic bone disease such as rickets or bone dysplasia such as osteogenesis imperfecta (Figures 7 and 8).
Safeguarding, the action taken to protect children from harm, is an important aspect of paediatric care. Orthopaedic surgeons are often the first healthcare professionals to suspect physical abuse or non-accidental injury (NAI) on the basis of children presenting with unexplained bony injury. Physical harm from inflicted injury, a concept that most orthopaedic surgeons are familiar with, is not the only cause for a safeguarding referral and a comprehensive assessment may reveal concerns regarding: neglect, emotional abuse or sexual abuse. Clinicians caring for children, have to consider all of these factors as a cause for concern and organize onward referral. This article focuses on inflicted skeletal injury, how to recognize and investigate it. Typical fractures of concern are discussed and illustrated along with consideration of differential diagnoses.
Safeguarding children in trauma and orthopaedics
2020, Orthopaedics and Trauma
Citation Excerpt :
Several reports in the literature document birth injury as the cause of CMLs; even rib fractures after birth injury have been described.67 CMLs have also been described after physical therapy for club foot treatment or after cannula insertion and it should be documented if the child has undergone such therapy.68–70 Family history or personal history of recurrent fractures and fractures after minor injury, should prompt consultation with a specialist paediatric endocrinologist or a geneticist to exclude metabolic bone disease such as rickets or bone dysplasia such as osteogenesis imperfecta (Figures 7 and 8).
Safeguarding, the action taken to protect children from harm, is an important aspect of paediatric care. Orthopaedic surgeons are often the first healthcare professionals to suspect physical abuse or non-accidental injury (NAI) on the basis of children presenting with unexplained bony injury. Physical harm from inflicted injury, a concept that most orthopaedic surgeons are familiar with, is not the only cause for a safeguarding referral and a comprehensive assessment may reveal concerns regarding: neglect, emotional abuse or sexual abuse. Clinicians caring for children, have to consider all of these factors as a cause for concern and organize onward referral. This article focuses on inflicted skeletal injury, how to recognize and investigate it. Typical fractures of concern are discussed and illustrated along with consideration of differential diagnoses.
Are classic metaphyseal lesions pathognomonic for child abuse? Two cases of motor vehicle collision-related extremity CML and a review of the literature
2020, Journal of Forensic and Legal Medicine
Citation Excerpt :
Inertial forces can cause CMLs in infants as the extremities are flung about during a whiplash event.4,11 Alternatively, combined forces delivered directly to the joint during forceful manipulation may also result in CMLs.12–14 A handful of cases of iatrogenic CMLs created within various healthcare settings as part of a prescribed treatment plan are reported in the medical literature and also describe sustained direct force across the ultimately injured joint (Table 1).
Long bone fractures at the infant growth plate, known as classic metaphyseal lesions (CMLs), raise a strong suspicion for abusive injury. CMLs persist as a hallmark for inflicted injury although a handful of documented cases of CMLs created by other, non-abusive mechanisms within various healthcare settings are scattered throughout the past few decades of medical literature. The forces required to sustain a CML are typically defined as a combination of tensile, compressive, or rotational energy applied to the metaphyseal regions of an infant's long bones. Recently, two separate child protection teams each encountered a case of CML discovered after reported motor vehicle collisions (MVC). This provoked a critical appraisal of the medical literature to inform clinical practice regarding MVCs as a potential mechanism for this fracture type and to remind clinicians that there is no single injury pathognomonic for abuse.
Using simulation to identify sources of medical diagnostic error in child physical abuse
2016, Child Abuse and Neglect
Citation Excerpt :
Justification for AB diagnosis in Scenario 4: As previously detailed, the presence of posterior rib fractures and an additional femur fracture are consistent with the diagnosis of abuse. Additionally, classic metaphyseal fractures are highly specific for abuse, particularly in the absence of any history of trauma to the involved extremity (Bilo et al., 2010; Burrell, Opfer, Berglund, Lowe, & Anderst, 2015; Flaherty et al., 2014; Kleinman, Perez-Rossello, Newton, Feldman, & Kleinman, 2011). In addition to the four scenarios, two social-risk roles for the parent-actor were developed in order to explore the effects of alterations in social risks on the participants’ performance.
Little is known regarding sources of diagnostic error at the provider level in cases of possible child physical abuse. This study examines medical diagnosis as part of medical management and not as part of legal investigation. Simulation offers the opportunity to evaluate diagnostic accuracy and identify error sources. We aimed to identify sources of medical diagnostic error in cases of possible abuse by assessing diagnostic accuracy, identifying gaps in evaluation, and characterizing information used by medical providers to reach their diagnoses. Eight femur fracture simulation cases, half of which were abuse and half accident, were created. Providers from a tertiary pediatric emergency department participated in a simulation exercise involving 1 of the 8 cases. Performance was evaluated using structured scoring tools and debriefing, and qualitative analysis characterized participants’ rationales for their diagnoses. Overall, 39% of the 43 participants made an incorrect diagnosis regarding abuse. An incorrect diagnosis was over 8 times more likely to occur in accident than in abuse cases (OR = 8.8; 95% CI 2 to 39). Only 58% of participants correctly identified the fracture morphology, 60% correctly identified the mechanics necessary to generate the morphology, and 30% of ordered all appropriate tests for occult injury. In misdiagnoses, participants frequently falsely believed the injury did not match the proposed mechanism and the history provided by the caregiver had changed. Education programs targeting the identified error sources may result in fewer diagnostic errors and improve outcomes. The findings also support the need for referral to child abuse experts in many cases.
Classic metaphyseal lesion acquired during physical therapy
2019, Clinical Imaging
Citation Excerpt :
Like the other isolated cases of CML occurring during medical management, this case report reconfirms excessive physical force as the etiology of CMLs [3–6]. Like the case reports of CML due to birth trauma and IV placement, the initial physical exam findings after the trauma were erythema and swelling that occurred shortly after the event [3–6]. For the CMLs after C-section, the erythema and swelling showed on physical exam within 48 h after birth and in our case, erythema and swelling were noted within hours after physical therapy on day 11 of life.
A classic metaphyseal lesion (CML) is highly specific for nonaccidental trauma. Missing CMLs can be devastating to the child as the child can continue to be exposed to inflicted trauma. Yet, there are rare case reports on CMLs that occur due to birth trauma, IV line placement, and treatment for clubfoot. We present a case of a CML in the tibia that occurred in the hospital secondary to physical therapy, that also caused a femoral shaft fracture, in a term child with hypertonic lower extremities secondary to myelomeningocele. Radiologists, as well as child abuse pediatricians, should be aware of the rare exception when CML is secondary to non-abusive injury.

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Case reportA witnessed case of a classic metaphyseal fracture caused during IV line placement in a child: Insight into mechanism of injury

Highlights

Abstract

Introduction

Section snippets

Case report

Discussion

Conflict of interest

Funding

Ethical approval

J Forensic Radiology Imaging

Skeletal trauma: general considerations

A critical review of the classic metaphyseal lesion: traumatic or metabolic?

Am J Roentgenol

Vitamin d deficiency in children and its management: review of current knowledge and recommendations

Pediatrics

Radiographic scoring method for the assessment of the severity of nutritional rickets

J Trop Pediatr

Classic metaphyseal lesion following external cephalic version and cesarean section

Pediar Radiol

Case report
A witnessed case of a classic metaphyseal fracture caused during IV line placement in a child: Insight into mechanism of injury