title: Rickets or abuse? A histologic comparison of rickets and child abuse-related fractures.
abstract: OBJECTIVE
  The bone changes of vitamin D deficiency rickets have been invoked as an alternate explanation for child-abuse related fractures identified through medical imaging. The lack of modern histopathologic comparisons between these two entities limits the abilities of the forensic pathologist to address this differential diagnosis, both in their autopsy reports and on the witness stand.
  
  
  METHODS
  We report a comparison of the histologic appearance of the bones in a two year old child with vitamin D deficiency rickets with fractures occurring in three young children with child abuse.
  
  
  RESULTS
  In the case of rickets, there was marked architectural disorganization of endochondral ossification at the costochondral junctions and growth plates of long bones. The child abuse-related fractures showed osteochondral callus at different stages of healing, either centered on a discrete fracture line or at metaphyses (e.g. classical metaphyseal lesions). In many instances, the healing fractures disrupted the line of endochondral ossification. In none of the child abuse-related fractures was there any similarity to the histologic appearance of rickets.
  
  
  CONCLUSIONS
  The maturation disturbance in the growth plate that occurs in rickets is a distinctive entity that cannot be confused histologically with healing fractures, including the classical metaphyseal lesion.
authors.affiliation: Ontario Forensic Pathology Service, Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada, ckepron@toh.on.ca.
authors.forename: Charis
authors.initials: C
authors.lastname: Kepron
authors.forename: Michael S
authors.initials: MS
authors.lastname: Pollanen
mesh_terms: D001344:Autopsy; D001706:Biopsy; D016723:Bone Remodeling; D001842:Bone and Bones / Q000000981:diagnostic imaging / Q000473:pathology*; D002423:Cause of Death; D002649:Child Abuse; D002675:Child, Preschool; D003937:Diagnosis, Differential; D017809:Fatal Outcome; D005260:Female; D049429:Forensic Pathology / Q000379:methods*; D017102:Fracture Healing; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000209:etiology* / Q000473:pathology*; D006801:Humans; D007223:Infant; D008297:Male; D011237:Predictive Value of Tests; D011859:Radiography; D012279:Rickets / Q000150:complications* / Q000000981:diagnostic imaging / Q000473:pathology*; D012307:Risk Factors