Classic metaphyseal lesion acquired during physical therapy

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.