By Ryan T. McGuire

In August 2024, an Indiana father, Tristan Dean Gerhardt, was charged after his six-month-old was found with fractures in all four limbs [1]. A skeletal survey revealed multiple fractures in both arms and legs. Oral injuries suggested something had been forced into the infant’s mouth. Treating physicians told investigators that most of the fractures appeared to be classic metaphyseal lesions (CMLs). These are “corner” or “bucket handle” fractures near the growth plates of immature bones. The doctors described them as highly indicative of non-accidental trauma.

Gerhardt cared for the baby during the day. He admitted to tightly swaddling the baby and to “rough diaper changes,” suggesting these routine activities might explain the injuries. Physicians rejected this explanation. They noted that normal handling, even forceful diaper changes, does not generate the kind of torsional and traction forces needed to produce CMLs. One doctor commented that if diaper-changing forces are strong enough to cause CMLs, those actions are abusive. [1]

The Gerhardt case presents a troubling factual context: a short-tempered caregiver, inconsistent explanations, and multiple injuries in various stages of healing. But CML findings don’t always appear in such fact-rich contexts. In some criminal and juvenile court cases, the state’s entire theory may rest on a radiologist’s statement that an X-ray shows a “classic metaphyseal lesion.” This post explains what CMLs are, why they’re treated as strong abuse indicators, and when that presumption may be wrong.

What Is a Classic Metaphyseal Lesion?
The metaphysis is the growing end of a long bone (the wider portion at the end of a long bone), just below the growth plate. A CML is a planar fracture through the spongy metaphyseal bone just beneath the growth plate. It often undermines the “bone collar” at the edge of the metaphysis [2].

The fracture has two characteristic appearances on X-ray. From one angle, a small triangular fragment appears at the metaphyseal edge. This is called a corner fracture. From another angle, a curved fragment appears parallel to the metaphysis, creating the appearance of a bone “handle,” called a bucket-handle fracture [3]. These are the same injury seen from different angles.

CMLs are most common in infants who cannot yet walk, especially those under one year of age. They typically appear in the distal femur, proximal and distal tibia, and proximal humerus [2]. Understanding why these fractures matter requires understanding how they form.

Why CMLs Are Treated as “Highly Specific” for Abuse
Pediatric radiology teaching materials describe CMLs as “highly specific indicators of child abuse in the first year of life” [2]. They are also the most common long-bone fracture found in infants who die from inflicted injury. Reference texts like Radiopaedia describe metaphyseal corner and bucket-handle fractures as the fracture pattern most specific for non-accidental trauma, present in roughly half of abused infants in some studies [3].

The mechanism involves torsional and tractional shear forces (twisting and pulling forces that stress the bone), the forces generated by twisting, yanking, or snapping an infant’s limb. Simple falls or everyday handling are not thought to produce these forces in otherwise healthy infants [2].

The epidemiologic data support this association. A 2011 American Journal of Roentgenology study found CMLs in high-risk infants but essentially none in children imaged for infections or malignancy [4]. A 2019 study in Pediatric Radiology examined young children with mild-to-moderate accidental trauma requiring X-rays. Fractures occurred, but no CMLs were documented with a clear accidental cause [5].

Clinical summaries also emphasize that about 95% of children with CMLs have at least one additional injury, such as other fractures, bruising, or intracranial bleeding [6].

When CMLs Are Not (or May Not Be) Abuse
Normal metaphyseal irregularities and vascular channels in infants can mimic CMLs on X-rays. Pediatric radiologists document these variants to prevent false abuse findings [5]. Accurate diagnosis requires standardized, high-quality skeletal surveys. In equivocal cases, follow-up imaging or ultrasound interpreted by pediatric radiologists familiar with these variants may be necessary.

Experts note that birth trauma rarely causes true CMLs except in difficult deliveries like breech births [7]. Conditions such as osteogenesis imperfecta, severe rickets, or other skeletal dysplasias can cause unusual fractures. However, available data suggest that classic corner and bucket-handle lesions are uncommon even in these diseases [6]. In some high-profile prosecutions, including State v. Grad, defense experts argued that metabolic or genetic bone disease could explain multiple fractures. Treating physicians and mainstream literature pointed to normal neonatal bone physiology and negative genetic testing [8].

Case reports also describe CML-type lesions caused during significant medical procedures, such as forceful limb flexion during IV-line placement [9]. These events show that CMLs are not mechanically unique to abuse. However, the forces involved are still high and usually well-documented. They do not represent routine caregiving or low-level accidents.

Conclusion: Strong Evidence, Not a Shortcut
In the Indiana “rough diaper change” case, the presence of multiple CMLs in all four limbs, oral injuries, a concerning pattern of behavior, and implausible explanations collectively support the suspicion of severe abuse.

Many dependency, severance, and custody disputes are harder. The only “injury” may be a subtle finding on X-ray that one expert calls a CML and another calls a variant. Given the high stakes, courts should resist treating CMLs as automatic proof of intentional abuse. This caution is particularly warranted when the lesion is borderline or disputed, when there are no other injuries or concerning social factors, and when alternative medical explanations have not been rigorously excluded.

Medical literature treats CMLs as powerful abuse indicators in pre-walking infants. Yet cases like Grad demonstrate the need for careful, evidence-based analysis, not reflexive reliance on diagnostic labels.

Sources

[1] Jerry Lambe, ‘Short-tempered’ father blamed ‘rough diaper changes’ for infant’s fractures in all 4 limbs: Police, Law&Crime (Aug. 1, 2024).

[2] Boston Children’s Hospital, Classic Metaphyseal Lesion (CML), pedradeducation2.

[3] Radiopaedia.org, Metaphyseal corner fracture.

[4] Kleinman et al., Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse, 197 Am. J. Roentgenology 1005 (2011).

[5] Eide et al., Prevalence of metaphyseal injury and its mimickers in otherwise healthy children under two years of age, 49 Pediatric Radiology 1051 (2019).

[6] Child Abuse, Metaphyseal Fractures, Imaging in Pediatrics, Clinical Tree (2022).

[7] In re R.G., 130 N.E.3d 1171 (Ind. Ct. App. 2019).

[8] State v. Grad, 2024-Ohio-5710, 178 Ohio St. 3d 58 (Ohio 2024).

[9] Burrell et al., A witnessed case of a classic metaphyseal fracture caused during IV line placement in a child: insight into mechanism of injury, 35 J. Forensic & Legal Med. 51 (2015).

Author

Ryan T. McGuire is a law clerk at Woodnick Law PLLC and a second-year student at the Sandra Day O’Connor College of Law. He leverages his master’s degree in philosophy to produce thorough legal research and writing, with a focus on family law matters. Ryan brings a strong foundation in legal analysis and academic interests spanning family, juvenile, and criminal law.