Pediatric Radiology

, Volume 47, Issue 12, pp 1622–1630 | Cite as

Biomechanics of the classic metaphyseal lesion: finite element analysis

Original Article



The classic metaphyseal lesion (CML) is strongly associated with infant abuse, but the biomechanics responsible for this injury have not been rigorously studied. Radiologic and CT-pathological correlates show that the distal tibial CML always involves the cortex near the subperiosteal bone collar, with variable extension of the fracture into the medullary cavity. Therefore, it is reasonable to assume that the primary site of bone failure is cortical, rather than intramedullary.


This study focuses on the strain patterns generated from finite element modeling to identify loading scenarios and regions of the cortex that are susceptible to bone failure.

Materials and methods

A geometric model was constructed from a normal 3-month-old infant’s distal tibia and fibula. The model’s boundary conditions were set to mimic forceful manipulation of the ankle with eight load modalities (tension, compression, internal rotation, external rotation, dorsiflexion, plantar flexion, valgus bending and varus bending).


For all modalities except internal and external rotation, simulations showed increased cortical strains near the subperiosteal bone collar. Tension generated the largest magnitude of cortical strain (24%) that was uniformly distributed near the subperiosteal bone collar. Compression generated the same distribution of strain but to a lesser magnitude overall (15%). Dorsiflexion and plantar flexion generated high (22%) and moderate (14%) localized cortical strains, respectively, near the subperiosteal bone collar. Lower cortical strains resulted from valgus bending, varus bending, internal rotation and external rotation (8–10%). The highest valgus and varus bending cortical strains occurred medially.


These simulations suggest that the likelihood of the initial cortical bone failure of the CML is higher along the margin of the subperiosteal bone collar when the ankle is under tension, compression, valgus bending, varus bending, dorsiflexion and plantar flexion, but not under internal and external rotation. Focal cortical strains along the medial margins of the subperiosteal bone collar with varus and valgus bending may explain the known tendency for focal distal tibial CMLs to occur medially. Further research is needed to determine the threshold of applied forces required to produce this strong indicator of infant abuse.


Biomechanics Child abuse Classic metaphyseal lesion Finite element analysis Microcomputed tomography Subperiosteal bone collar 


Compliance with ethical standards

Conflicts of interest



  1. 1.
    Kleinman PK, Perez-Rossello JM, Newton AW et al (2011) Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol 197:1005–1008CrossRefPubMedGoogle Scholar
  2. 2.
    Strouse PJ, Boal DKB (2013) Child abuse. In: Coley BD (ed) Caffey’s pediatric diagnostic imaging. Elsevier, Philadelphia, pp 1587–1598Google Scholar
  3. 3.
    Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL (2014) Evaluating children with fractures for child physical abuse. Pediatrics 133:e477–e489CrossRefPubMedGoogle Scholar
  4. 4.
    Servaes S, Brown SD, Choudhary AK et al (2016) The etiology and significance of fractures in infants and young children: a critical multidisciplinary review. Pediatr Radiol 46:591–600CrossRefPubMedGoogle Scholar
  5. 5.
    Ruess L, O’Connor SC, Quinn WJ et al (2003) An animal model for the classic metaphyseal lesion of child abuse. Pediatr Radiol 33:S112Google Scholar
  6. 6.
    Thackeray JD, Wannemacher J, Adler BH, Lindberg DM (2016) The classic metaphyseal lesion and traumatic injury. Pediatr Radiol 46:1128–1133CrossRefPubMedGoogle Scholar
  7. 7.
    Kleinman PL, Zurakowski D, Strauss KJ et al (2008) Detection of simulated inflicted metaphyseal fractures in a fetal pig model: image optimization and dose reduction with computed radiography. Radiology 247:381–390CrossRefPubMedGoogle Scholar
  8. 8.
    Thompson A, Bertocci G, Kaczor K et al (2015) Biomechanical investigation of the classic metaphyseal lesion using an immature porcine model. AJR Am J Roentgenol 204:503–509CrossRefGoogle Scholar
  9. 9.
    Walsh CJ, Phan CM, Misra M et al (2010) Women with anorexia nervosa: finite element and trabecular structure analysis by using flat-panel volume CT. Radiology 257:167–174CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Zhang N, Magland JF, Rajapakse CS et al (2013) Assessment of trabecular bone yield and post-yield behavior from high-resolution MRI-based nonlinear finite element analysis at the distal radius of pre-menopausal and postmenopausal women susceptible to osteoporosis. Acad Radiol 20:1584–1591CrossRefPubMedGoogle Scholar
  11. 11.
    Chang G, Honig S, Brown R et al (2014) Finite element analysis applied to 3-T MR imaging of proximal femur microarchitecture: lower bone strength in patients with fragility fractures compared with control subjects. Radiology 272:464–474CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kleinman PK, Marks S (1996) A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. AJR Am J Roentgenol 166:1207–1212CrossRefPubMedGoogle Scholar
  13. 13.
    Kleinman PK, Marks S, Blackbourne B (1986) The metaphyseal lesion in abused infants: a radiologic histopathologic study. AJR Am J Roentgenol 146:896–905CrossRefGoogle Scholar
  14. 14.
    Kleinman PK, Marks S (1995) Relationship of the subperiosteal bone collar to metaphyseal lesions in the abused infants. J Bone Joint Surg 77:1471–1476CrossRefPubMedGoogle Scholar
  15. 15.
    Kleinman PK, Marks S, Richmond J, Blackbourne B (1995) Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants. AJR Am J Roentgenol 165:647–650CrossRefPubMedGoogle Scholar
  16. 16.
    Tsai A, McDonald AG, Rosenberg AE et al (2014) High-resolution CT with histopathological correlates of the classic metaphyseal lesion of infant abuse. Pediatr Radiol 44:124–140CrossRefPubMedGoogle Scholar
  17. 17.
    Kepron C, Pollanen MS (2015) Rickets or abuse? A histologic comparison of rickets and child abuse-related fractures. Forensic Sci Med Pathol 11:78–87CrossRefPubMedGoogle Scholar
  18. 18.
    Kleinman PK, Blackbourne BD, Marks SC et al (1989) Radiologic contributions to the investigation and prosecution of cases of fatal infant abuse. N Engl J Med 320:507–511CrossRefPubMedGoogle Scholar
  19. 19.
    Hirsch C, Evans FG (1965) Studies on some physical properties of infant compact bone. Acta Orthop Scand 35:300–313CrossRefPubMedGoogle Scholar
  20. 20.
    Shahar R, Zaslansky P, Barak M et al (2007) Anisotropic Poisson’s ratio and compression modulus of cortical bone determined by speckle interferometry. J Biomech 40:252–264CrossRefPubMedGoogle Scholar
  21. 21.
    Ding M, Dalstra M, Kabel J et al (1997) Age variations in the properties of human tibial trabecular bone. J Bone Joint Surg 79:995–1002CrossRefGoogle Scholar
  22. 22.
    Nafei A, Danielsen CC, Linde F, Hvid I (2000) Properties of growing trabecular ovine bone. Part I: mechanical and physical properties. J Bone Joint Surg (Br) 82:910–920CrossRefGoogle Scholar
  23. 23.
    Kilborn SH, Trudel G, Uhthoff H (2002) Review of growth plate closure compared with age at sexual maturity and lifespan in laboratory animals. Contemp Top Lab Anim Sci 41:21–26PubMedGoogle Scholar
  24. 24.
    Pearce AI, Richards RG, Milz S et al (2007) Animal models for implant biomaterial research in bone: a review. Eur Cell Mater 13:1–10CrossRefPubMedGoogle Scholar
  25. 25.
    Ulrich D, van Rietbergen B, Weinans H, Ruegsegger P (1998) Finite element analysis of trabecular bone structure: a comparison of image-based meshing techniques. J Biomech 31:1187–1192CrossRefPubMedGoogle Scholar
  26. 26.
    Schileo E, Taddei F, Cristofolini L, Viceconti M (2008) Subject-specific finite element models implementing a maximum principal strain criterion are able to estimate fracture risk and fracture location on human femurs tested in vitro. J Biomech 41:356–367CrossRefPubMedGoogle Scholar
  27. 27.
    Li X, Viceconti M, Cohen MC et al (2015) Developing CT based computational models of pediatric femurs. J Biomech 48:2034–2040CrossRefPubMedGoogle Scholar
  28. 28.
    Barber I, Perez-Rossello JM, Wilson CR, Kleinman PK (2015) The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatr Radiol 45:69–80CrossRefPubMedGoogle Scholar
  29. 29.
    Silverman FN (1953) The roentgen manifestations of unrecognized skeletal trauma in infants. AJR Am J Roentgenol 69:413–427Google Scholar
  30. 30.
    Caffey J (1957) Some traumatic lesions in growing bones other than fractures and dislocations: clinical and radiological features. Br J Radiol 30:225–238CrossRefPubMedGoogle Scholar
  31. 31.
    Snedecor ST, Wilson HB (1949) Some obstetrical injuries to the long bones. J Bone Joint Surg 31A:378–384CrossRefPubMedGoogle Scholar
  32. 32.
    Caffey J (1972) On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child 124:161–169CrossRefPubMedGoogle Scholar
  33. 33.
    Tsai A, Perez-Rossello J, Breen M, Kleinman P The distal tibial classic metaphyseal lesion: radiographic spatial distribution and biomechanical implications. Pediatr Radiol 47:S157–S158Google Scholar
  34. 34.
    Helgason B, Perilli E, Schileo E et al (2008) Mathematical relationships between bone density and mechanical properties: a literature review. Clin Biomech 23:135–146CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Department of Radiology, Harvard Medical SchoolBoston Children’s HospitalBostonUSA
  2. 2.Department of Mechanical EngineeringUniversity of UtahSalt Lake CityUSA

Personalised recommendations