Pediatric Radiology

, Volume 48, Issue 7, pp 973–978 | Cite as

The distal tibial classic metaphyseal lesion: medial versus lateral cortical injury

  • Andy Tsai
  • Patrick R. Johnston
  • Jeannette M. Perez-Rossello
  • Micheál A. Breen
  • Paul K. Kleinman
Original Article



The distal tibia is a common location for the classic metaphyseal lesion (CML). Prior radiologic-pathologic studies have suggested a tendency for medial, as opposed to lateral, cortical injury with the CML, but there has been no formal study of the geographic distribution of this strong indicator of abuse.


This study compares medial versus lateral cortical involvement of distal tibial CMLs in a clinical cohort of infants with suspected abuse.

Materials and methods

Reports of 1,020 skeletal surveys performed for suspected abuse (July 2005-June 2016) were reviewed. Twenty-six distal tibial CMLs (14 unilateral, 6 bilateral) with anteroposterior (AP) and lateral projections on the initial skeletal survey and at least an AP view on the follow-up survey were identified in 20 infants. Two blinded pediatric radiologists determined if the medial and/or lateral margins of the distal tibial metaphysis were involved by the CML.


Average interreader absolute agreement and kappa scores were 0.69-0.90 and 0.45-0.72, respectively. Average intrareader absolute agreement and kappa scores were 0.65-0.88 and 0.44-0.57, respectively. Analyses showed that the distal tibial CML almost always involved the medial cortical margin (reader 1=89%, reader 2=88%, pooled=89%) and the fracture infrequently involved the lateral cortical margin (reader 1=12%, reader 2=38%, pooled=26%). The percentage point difference between fracture involvement in medial and lateral margins was statistically significant from zero (P<0.001).


The distal tibial CML is most often encountered medially; lateral involvement is uncommon. This observation should help guide the radiologic diagnosis and could have implications for understanding the biomechanics of this distinctive injury.


Child abuse Classic metaphyseal lesion Fracture Infants Radiography Skeletal survey Tibia 


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 et al (2014) American Academy of Pediatrics Committee on child abuse and neglect; section on radiology, American Academy of Pediatrics; section on endocrinology, American Academy of Pediatrics; section on Orthopaedics, American Academy of Pediatrics; Society of Pediatric Radiology. 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.
    Silverman F (1953) The roentgen manifestations of unrecognized skeletal trauma in infants. AJR Am J Roentgenol 69:413–427Google Scholar
  6. 6.
    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
  7. 7.
    Kleinman PK, Marks SC, Richmond J et al (1995) Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants. AJR Am J Roentgenol 165:647–650CrossRefPubMedGoogle Scholar
  8. 8.
    Kleinman PK, Marks SC (1996) A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. AJR Am J Roentgenol 166:1207–1212CrossRefPubMedGoogle Scholar
  9. 9.
    Barber I, Perez-Rossello JM, Wilson CR et al (2015) The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatr Radiol 45:69–80CrossRefPubMedGoogle Scholar
  10. 10.
    Kleinman PK, Marks SC, Blackbourne B (1986) The metaphyseal lesion in abused infants: a radiologic histopathologic study. AJR Am J Roentgenol 146:896–905CrossRefGoogle Scholar
  11. 11.
    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
  12. 12.
    American College of Radiology (2006) ACR practice guideline for skeletal surveys in children (res. 47, 17, 35). In: American College of Radiology. ACR standards. American College of Radiology, Reston, pp 203–207Google Scholar
  13. 13.
    SAS Institute Inc (2015) SAS/STAT® 14.1 User Guide. SAS Institute Inc, CaryGoogle Scholar
  14. 14.
    Cicchetti DV (1994) Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess 6:284–290CrossRefGoogle Scholar
  15. 15.
    Lachin JM (2010) Biostatistical methods: the assessment of relative risks, 2nd edn. John Wiley & Sons, Inc., New YorkCrossRefGoogle Scholar
  16. 16.
    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
  17. 17.
    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
  18. 18.
    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
  19. 19.
    Tsai A, Coats B, Kleinman P (2017) Biomechanics of the classic metaphyseal lesion: finite element analysis. Pediatr Radiol 47:1622–1630CrossRefPubMedGoogle Scholar
  20. 20.
    Karmazyn B, Duhn RD, Jennings SG et al (2012) Long bone fracture detection in suspected child abuse: contribution of lateral views. Pediatr Radiol 42:463–469CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Radiology, Harvard Medical SchoolBoston Children’s HospitalBostonUSA

Personalised recommendations