Multiple unexplained fractures in infants and child physical abuse

J Steroid Biochem Mol Biol. 2018 Jan;175:18-22. doi: 10.1016/j.jsbmb.2016.09.012. Epub 2016 Sep 15.


When an infant presents with X-rays showing multiple unexplained fractures in various stages of healing (MUFVSH), the child is usually diagnosed with child abuse based on criteria of the Academy of Pediatrics' Committee on Child Abuse and Neglect (AAPCCAAN). Almost always, the infant is subsequently removed from the home and civil or criminal proceeding commence. It may be that healing infantile rickets or other poorly understood metabolic bone disorders of infancy are responsible for these x-rays. Activated vitamin D is a seco-steroid hormone, whose mechanism of action is genetic regulation. Lack of it can result in musculoskeletal defects known as rickets. Low calcium can also cause rickets. However, it is clear that experts for the state believe that the x-rays in these cases are so definitive as to be pathognomonic for child abuse. Therefore, if the caregivers deny abusing their infants, experts following American Academy of Pediatric's Committee on Child Abuse and Neglect. guidelines are essentially claiming that x-rays showing multiple unexplained fractures in various stages of healing are lie detector tests. However, it is not widely appreciated that the gold standard for the diagnosis of rickets is a bone biopsy, not x-rays, as radiologists miss biopsy proven rickets 80% of the time; that is, 4 out of 5 infants with rickets will have normal x-rays. In this article we provide reports of two cases and their outcomes. We discuss information about healing infantile rickets and an example of common sense medical conclusions in these cases. This information could lead to a significant reduction in the number of innocent parents having their infant removed or sent to prison.

Keywords: American Academy of Pediatrics’ Committee on Child Abuse and Neglect; Child abuse; Child physical abuse; Classic metaphyseal lesion; Infantile rickets; Metabolic bone disease; Multiple unexplained fractures; Rickets; Total parental nutrition; Vitamin D.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Biopsy
  • Bone and Bones / diagnostic imaging*
  • Bone and Bones / drug effects
  • Bone and Bones / metabolism
  • Bone and Bones / pathology
  • Child
  • Child Abuse / diagnosis*
  • Diagnostic Errors
  • Fractures, Bone / diagnostic imaging*
  • Fractures, Bone / diet therapy
  • Fractures, Bone / metabolism
  • Fractures, Bone / pathology
  • Humans
  • Infant
  • Male
  • Radiography
  • Rickets / diagnostic imaging*
  • Rickets / diet therapy
  • Rickets / metabolism
  • Rickets / pathology
  • Vitamin D / administration & dosage
  • Vitamin D / metabolism*


  • Vitamin D