Iatrogenic Flexion-Related Classic Metaphyseal Lesion of the Distal Tibia: Three Cases

Classic metaphyseal lesions (CMLs) should raise concern for nonaccidental trauma. However, iatrogenic causes for CMLs have increasingly been described and warrant close consideration. Increasing the clinical understanding of CML mechanics and their relation to often routine medical procedures will enhance provider awareness and expand the differential diagnosis when these otherwise highly concerning injuries are identified.

We describe three clinical cases where suspected iatrogenic dorsiflexion or plantar flexion resulted in an isolated distal tibia CML. Respectively, we present heel-stick testing and i.v. line placement as clinical correlates of these two mechanisms. Although prior reports have aimed to describe iatrogenic CML etiologies, they have not focused on dorsiflexion or plantar flexion as predominant mechanisms of injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians are critical to the surveillance and identification of nonaccidental trauma. Given that children oftentimes present to the emergency department with subtle yet concerning signs of maltreatment, an emergency physician must be aware of the potential causes of injury as well as the recommended response. Although avoiding missed cases of abuse and improving the detection of injuries is crucial for child health and well-being, failing to consider or recognize alternative explanations could also have serious implications for a child and their caregivers.