Soon we will see that the urban legend of
radiographic evidence of child abuse proven just that – nothing but
legend. Since 1946 – and more so since
1986 – the pediatric and radiological medical community has been taught and come
to believe as gospel that there are certain fractures in children that are
pathognomonic of child abuse. Described as
a bucket handle or corner fracture because of how they allegedly appear on
x-ray films, peditaricians, radiologist, nurses, police officers, prosecutors,
judges and social workers are taught that these fractures are highly specific
of child abuse. These alleged fractures
have become known as “classic metaphyseal legions” or “CML”, a phrase coined by
Dr. Paul Kleinman in his 1986 article “The Metaphyseal Lesion in Abused
Infants: A Radiologic-histopathologic Study.” AJR 196; 146:895-905.
For at least the past two decades though, this
assumption has routinely been challenged.
And with the advent of better and more available bone imagining tools,
the evidence is proving that not only are these alleged fractures not evidence
of abuse – but they are not in reality fractures at all.
Sadly though, the CML legend remains the medical
standard. So at best, the issue becomes
a battle of experts. Unfortunately for
the criminal defendant – often an honest loving parent – the cost to identify
and acquire the various medical experts can amount to tens of thousands of dollars. And, a typical criminal defense lawyer may
herself be undereducated on the topic so much so as to not know what medical
evidence to have evaluated and by which medical specialty. These fracture cases involve in the least
adult and pediatric genetics, pediatrics, radiology, bone specialists and
histopathology – not to mention the lab testing and additional radiology that
is necessary to design a sophisticated defense.
And, without that understanding, often the criminal defense lawyer
herself may not request from the Court funds for the appropriate expert
consultants and witnesses.
The government though has the treating doctors as
their experts at no cost to prosecute felonious assault and felony child
endangering charges. This expert
testimony generally goes unchallenged by the police investigators. Even worse, the parent will not have had the opportunity
to review the medical records, identify experts and obtain medical expert
reports until well after having been publically accused and charged criminally
of abusing a child.
Even if criminal charges are not filed, the
government typically petitions the Court for a finding of abuse. Ohio has Section 2151.031 of the Ohio Revised
Code. That provision, like most states,
allows an inference that a child was abused where the parents cannot provide an
explanation for the injuries.
A very typical child fracture case finds itself to the
attention of law enforcement when parents self-report the child to a
pediatrician or emergency department with some apparent injury or difficulty a
child seems to be experiencing. The child generally has no external evidence of
injury or abuse, e.g. no bruising, swelling, or scrapes. There is almost always no witness to any
actual abuse. With the routine
examination or x-ray, multiple alleged fractures are identified and the child
is immediately placed in protective care.
The parents are shocked and heartbroken to hear the
diagnosis of multiple fractures. The
shock is matched by their confusion. They are immediately subject to
questioning by law enforcement. They
often do not understanding that the officers are investigating them as suspects
of the alleged abuse. When the parents
have no explanation for the alleged fractures, the investigators immediately
presume abuse as there was no other reasonable explanation for the fractures
offered by parents. Never though do the
doctors, nurse or police officers explain that there is debate among medical
professionals as to whether these bucket handle and corner fractures actual
exists.
Ignore for the moment how complicated is the growth
of young bone, the suspicion that healthy and happy parents would cause such
abuse is unique to only these child fracture cases. It is sadly though the heart of the problem
with such cases. As Dr. James LeFanu
wrote that “[t]he diagnosis of fractures must be highly improbable in the
absence of the relevant clinical signs of injury. It seems highly improbable that a small baby
who has allegedly been the victim of repetitive physical assault should
nonetheless appear well with no physical stigma of injury such as bruises or
soft tissue injury other than the presenting injury.” LeFanu, James, M.D., The Misdiagnosis of
Metaphyseal Fractures: A Possible Cause of Wrongful Accusations of Child Abuse,
Nov. 25, 2009. The finding of abuse in such cases is saying only that the
parents are, in the words of Dr. Marvin Miller, “deceptive parents who have
maliciously designed a way of repeatedly injurying the bones of their child
without leaving any telltale traces of injury to the skin.” Miller, Marvin, MD, The Lesson of Temporary
Brittle Bone Disease: All Bones are Not
Created Equal, Bone 33 (2003) 466.
Why then is this the accepted belief among doctors, nurses,
social workers, prosecutors, police officers and judges? In 1995, Dr. Paul Kleinman conducted a study
of just 31 deceased infants to in essence prove his 1986 findings. It appears though there is little more to
support his findings other than this 1995 article “Inflicted Skeletal Injury: A
Post-Mortem Radiologic-histopathological Study in 31 Infants.” AJR 1995; 165:647-650. Until recently, there was no comprehensive evaluation
of any and all research supporting these CML assumptions.
In 2014, radiologist Dr. David Ayoub, pediatrician Dr.
Charles Hyman, histopathologist Dr. Marta Cohen, and pediatric geneticist, Dr.
Marin Miller, engaged in a study to “review the hypothesis that classic
metaphyseal lesions represent traumatic changes in abused infants and compare
these lesions with healing rickets.”
Ayoub, et al. A Critical Review of the Classic Metaphyseal Lesion:
Traumatic or Metabolic?; AJR 202, January 2014. The authors researched the
National Library of Medicine for articles addressing the subject of the
CML. There were only nine studies in the
peer reviewed literature on the subject – they were published between 1986 and
1998 by the same principal investigator, Dr. Paul Kleinman. This is the same Dr. Paul Kleinman who coined
the phrase “classic metaphyseal lesion.”
The review of Dr. Kleinman’s research found that it
suffered from a number of defects:
1. There
was no control group that tested the prevalence of the metaphyseal lesion in
non-abused children.
2. There
was little evidence to confirm that there was actual abuse so as to confirm the
CML finding was related to abuse. These
were not “witnessed abuse” cases.
3. The
findings have not been independently replicated in peer-reviewed literature.
4. Pediatricians
and radiologists are taught that these fractures are caused by violent whipping
of the child. The CML is allegedly a
fracture parallel to the chrondroosseous junction – where the bone meets the
cartilage. Which is not consistent with the
“violent shaking as the infant is held
by the trunk and extremities” that Dr. Kleinman proposes to cause the parallel
injury.
5. There
is typically no evidence of bleeding in near the fracture which is an area that
is extremely vascular because of its role bone growth.
6. The
radiographic depiction of these CMLs arguably resembles the irregular
thickening of the perichondrial ring.
That ring surrounds the end of growing bone to provide it protection and
support. If the bone grows irregularly,
this perichondrial ring can give the impression of a bucket or corner fracture
where the diaphysis meets the metaphysis and epiphysis.
7. Last
and most important, modern CT and MRI technology is now available to test
current x-ray findings – but not available to test old x-ray findings. We cannot go back to old patients and conduct
CT and MRI on the patient. When comparing
suspicions of fractures based on x-rays to CT scans of the same bone,
radiologist are learning that what was suspected as a fracture is instead a
bone irregularity or the thickening of the perichondrial ring.
Remember that understanding the
radiographic tools to diagnose these fractures is critical to understanding the
reliability of the findings of the radiologist.
These are ultimately questions of the mineralization of the bone as
mineralization is crucial to bone strength.
It is well settled that there must be a loss of bone mineralization of
some 20-30% before the demineralization can be detected on a simple x-ray. Hence, with the prevalence of these better
imaging technologies, we have a new opportunity to test comparisons between
x-ray finds and CT or MRI findings. We
do though need a commitment to conduct this
research and record the findings as doctors are treating suspicions of abuse in
their day to day practices. Without that
commitment, we risk losing critical evidence to support findings of past
wrongful convictions for child abuse.
With that, Drs Ayoub, Hyman, Cohen and Miller conclude
that the decades old presumption that a CML is indicate of abuse “is poorly
supported.” They recommend that “[u]ntil
classic metaphyseal lesions are experimentally replicated and independently
validated, their traumatic origin remains unsubstantiated.” Interestingly, one frequent expert witness
for the government reported to this writer the preliminary results of his
recent study. He described his “witnessed abuse study” – meaning cases where
injured children came to the clinic with actual witnesses of abuse. The radiological evaluation of these
witnessed abuse patients in his study was not proving to show classic
metaphyseal lesions in these patients.
This is nothing new in abuse medicine. The criminal justice system experienced the
same medical presumptions with Shaken Baby Syndrome; parents were convicted and
imprisoned only for the system to discover later the fallacy of the SBS
diagnosis.
On a daily basis there are loving parents accused of
injuring a child without any external evidence of injury or witness to
abuse. Not only are families torn apart,
but the accused parent is convicted and imprisoned for considerable
periods. As Drs Ayoub, Hyman, Cohen and
Miller suggest we must remain suspicious of the suggestion that these lesions
have a traumatic origin.
