To The Editor
In the December 2016 edition of AFP, in the article by Walker et al. (Are There Hallmarks of Child Abuse I: Osseous Injuries), the authors present three photomicrographs of infant metaphyses that purport to show metaphyseal fractures. These photomicrographs do not include separate descriptions or photographs of the corresponding gross pathologic findings of these metaphyses, which should show gross bony defects such as intraosseous hemorrhage, soft tissue hemorrhage and/or swelling and, perhaps, visible fracture callus. Without correlation to such gross anatomic pathologic findings, these photomicrographs more than likely represent nothing more than histological processing artifacts, or “chatter” marks as they are commonly called. I have attached several photomicrographs of the costochondral junctions of infants ranging in age from 2 to 7 months who died of natural causes. None of these infants demonstrated any signs of injury, including no signs of fractures on complete radiographic examination. At postmortem examination, all of the costochondral junctions were grossly normal, externally and after sectioning, without signs of fracture. No chest wall contusions were observed. The first three figures (Images 1 to 3) are from infants who had no evidence of injury and no history or signs of terminal resuscitative procedures. Image 4 demonstrates near complete artifactual separation through the metaphysis with associated artifactual folding of the cartilaginous epiphysis. Image 5 shows microscopically demonstrable hemorrhage within the separated metaphysis that extends into the epiphyseal cartilage, despite the fact that no such hemorrhage was observed grossly.
Image 1:
Three-month-old female.
Image 2:
Seven-month-old female.
Image 3:
Five-month-old female.
Image 4:
Four-month-old male.
Image 5:
Five-month-old male.
I have heard it stated on more than one occasion that microscopic tissue disruption and microscopic hemorrhage, standing alone, in the absence of visible gross hemorrhage, should not be considered as a sign of physical injury. I would submit that this caveat is most appropriate with reference to the findings in this article.
W Massello MD