Bucket-handle fracture

• bucket-handle fracture describes the radiological appearance of a type of metaphyseal fracture associated with non accidental injury
• metaphyseal fractures have been widely held as one of the strongest radiological indicators of physical abuse since Caffey's description of the 'battered baby' in 1957
  • metaphyseal fractures are reported as either corner or bucket-handle fractures which is dependent upon the angle at which the x-ray film is taken
    • are small fractures and difficult to visualise, especially in their acute phase when they can be confused with normal variants and, therefore, need careful investigation with serial x-rays and specialised radiological views of the area
      • bucket-handle and corner fractures are classically found in infants and toddlers and they occur most commonly in the femur and tibia
        • fracture plane is through the metaphyseal primary spongiosa
          • when the fracture traverses the entire metaphysis visualisation of both the central and peripheral components creates the appearance of a bucket handle fracture
            • note that variations in position, radiographic projection and size of the fracture fragment result in a spectrum of radiological appearances
              • visualization of only the thicker peripheral component creates the appearance of a corner fracture, at other times the fracture line may be incomplete with separation of only a short arc of bone
            • in an infant without underlying bone disease such metaphyseal fractures are highly specific for non accidental injury often occur with repetitive acceleration and deceleration forces as an infant is shaken, but may also reflect torsional forces as an infant's limb is twisted
              • a fracture at the metaphysis of a long bone which appears as a chip off the edge of the bone, typically seen in child abuse, but a somewhat similar appearance may also occur with scurvy, rickets, Menkes syndrome and severe osteogenesis imperfecta
              • metaphyseal fractures,however, are not exclusive to child abuse, they have also been reported in positional talipes correction, physiotherapy and following child birth
            • radiological dating of such fractures is difficult as subperiosteal new bone formation is variable

Reference:

• 1. Grayev AM et al. Metaphyseal fractures mimicking abuse during treatment for clubfoot. Pediatr Radiol 2001;31;559-563.