IS case 462: Non-accidental trauma

Keith Forrest Dockery, MD, MS

University of Rochester

Imaging Sciences URMC 2010
Publication Date: 2010-08-30


Patient is a 2-month-old female with unexplained bruising and fractures on outside imaging.


See images


Non-accidental trauma


Skeletal injuries to the child are a) the most common type of injury in physical abuse, b) typically caused by a manual mechanism (think shaking/twisting), and c) not usually life threatening (in contrast to head/CNS trauma).

Indications for skeletal survey according to the American College of Radiology (ACR) [1] include: suspected physical abuse in infants and children; suspected skeletal dysplasias, syndromes, or metabolic disorders; and suspected neoplasia.

Kleinman coined the term classic metaphyseal lesion (CML) to describe the most specific finding of child abuse, a.k.a. "bucket handle" fracture or "corner" fracture, described earlier by John Caffey. This type of fracture results from shearing of the metaphysis during manual shaking/twisting of the extremity, viz., this mechanism is unusual in other accidental types of extremity trauma (think BBFF - both bones forearm fractured). Note that long bone transverse fractures can also occur as a result of direct trauma in abuse. The CML is seen in up to 50% of abuse children under 18 months of age. CML’s are essentially lesions of children under 2 years of age.

The babygram should not be utilized as a substitute for dedicated skeletal survey views. Imaging is generally in the AP projection, with selected lateral views, see facsimile of tables from Kleinman [2] (Fig.1). Extremities should be imaged in segmental fashion for suspected abuse. Additional oblique views of the ribs may increase sensitivity. Additional dedicated extremity or joint projections are used at the discretion of the radiologist.

In the current case, fractures were described as follows: healing fracture of right clavicle; healing fracture of the posterior left 8th rib and acute fractures left posterior 9th and 10th ribs (images not shown); metaphyseal fracture of the left proximal medial tibia, probably healing; corner fractures of the right and left distal tibias, especially anteriorly; and metaphyseal fracture of the right distal radius at the posterior radial edge.

Numerous fractures of different ages, involving posterior ribs and long bone metaphyses, indicate non-accidental trauma in a patient without other history of massive trauma and with normal bone density.


  1. ACR Practice Guideline for Skeletal Surveys in Children (Res. 47,17, 35). In: American College of Radiology: ACR Standards. Reston, VA: American College of Radiology, 2006:145-149.
  2. Kleinman PK. Diagnostic imaging for child abuse: current concepts and controversies. Advanced Pediatric Emergency Medicine Assembly. April 14-16, 2009. Boston, MA. [PDF]
  3. Kleinman PK. Diagnostic Imaging of Child Abuse, 2nd ed. Boston: Mosby, 1998.

4 images