Bucket Handle and Corner Fractures
Radiology Cases in Pediatric Emergency Medicine
Volume 4, Case 2
Rodney B. Boychuk, M.D.
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 2-month-old female who is brought to an
acute care clinic for cough, runny nose, fussiness, and
decreased movement of the left arm. The infant has
mild nasal congestion, bilateral otitis media, and an
angulated tender swelling in the left upper arm with
minimal movement of the left arm.
According to the mother, the infant cries a lot when
she is dressed and has not been moving her arm for
approximately 3 days. The mother also notes swelling,
but is uncertain about the day of onset. She said that
the father told her that while he was cleaning the house,
he tripped over the infant's brother and accidentally
stepped on the baby. She did not seek medical
attention earlier because she thought the arm was just
sore from the incident.
A skeletal survey is done.
View lower extremity:
The left distal femur metaphysis is shown here.
Three images are displayed. The top image is taken on
the day of presentation to the E.D. Corner fractures on
both sides of the distal femur are barely visible. The
middle image, taken two days later, shows the two
corner fractures more clearly. The bottom image, taken
9 days after presentation shows some periosteal
reaction. The pattern of healing shows a bucket handle
appearance at the inferior border of the metaphysis.
View upper extremity:
The upper extremity radiograph shows a
transverse fracture of the mid-portion of the shaft of the
In addition to the fractures displayed above, this
patient also has a small bucket handle fracture of the
distal humeral metaphysis and a small bucket handle
fracture of the distal tibia. Both of these are very hard to
see (images not shown). These findings are compatible
with child abuse.
A CT scan of the head is normal, and an inpatient
ophthalmologic evaluation does not reveal any retinal
View diagram of fractures.
This diagram illustrates the phenomenon of corner
fractures and bucket handle fractures. Corner fractures
and bucket handle fractures are similar in etiology
despite their different names. A small bucket handle
fracture may appear as a corner fracture on the
radiograph depending on the angle of the radiograph. A
true corner fracture is still similar to a small bucket
This is a 9-month-old who is brought to an acute
care clinic after noting something is wrong with the
infant's arm after a toy was pulled away from him. The
infant was in the care of the baby-sitter at that time.
Mother was working at night.
Physical exam reveals a 9-month-old male,
approximately 50th percentile for height and weight. A
bruise at the lateral edge of the left eye and bruise of
the left pinnae are noted. The child is clinging to the
mother, quite apprehensively. The right elbow shows
2+ swelling. The child is reluctant to move the right
elbow because of pain. The sensation and circulation
to the hand appears normal. Above the right elbow,
ecchymosis is noted anteriorly and posteriorly. No
definite crepitus is detected. The infant holds the right
elbow in full extension. Any flexion beyond 10-15
degrees results in pain, with the child crying.
A skeletal survey is obtained.
View right elbow.
Multiple views of the right elbow demonstrate a
distal humeral bucket handle type fragment. The thin
fragment represents a section of the distal metaphysis.
Although the physis (growth plate) cannot be seen
radiographically, it is evident that the fracture must go
through the physis to splinter off a section of the distal
metaphysis as seen. The radius should be pointing at
the capitellum in all views. In the oblique lateral view,
the radius is not pointing straight at the capitellum
indicating that the epiphysis of the humerus (capitellum)
is displaced. The AP view shows that the capitellum is
displaced medially. This type of fracture is known in the
orthopedic literature as a "transepiphyseal"
(transphyseal) fracture. This is not a true bucket handle
fracture, although it resembles a bucket handle.
A follow-up view of this elbow is taken one month
View follow-up view of elbow.
Extensive periosteal reaction and healing are noted
in the distal humeral metaphysis. What initially
appeared to be a small fracture upon presentation,
results in substantial changes associated with healing.
Most of the fracture is through the physis, however, this
is not ossified and not visible radiographically. These
extensive changes are evidence of healing of the
View patient's tibia.
The lower extremity radiographs demonstrate
periosteal new bone formation along the lateral aspect
of the shaft of the left tibia, presumably secondary to a
healing subperiosteal hematoma. This finding is very
subtle and can be best seen on the AP view on the
lateral aspect adjacent to the fibula.
View focused view of tibia.
This focused view of the patient's tibia points to the
area of periosteal reaction.
A technetium bone scan is recommended to
determine if there are any other skeletal injuries, which
cannot be visualized radiographically. A radionuclide
bone scan with vascular flow scan is performed.
View bone scan.
Delayed static images of the bone scan showed
increased tracer localization in multiple sites, including
the left clavicle, both humeri (R>L), both ulnae (not
shown), and both tibiae (L>R). Findings were felt to be
most likely traumatic in etiology.
Images obtained soon after injection ("blood pool"),
are mainly a function of blood flow and the degree of
soft tissue hyperemia. The early images are useful in
the diagnosis of infectious and traumatic lesions, as
well as malignant bone tumors. After a delay of 2-4
hours, the concentration of the phosphate compound by
the bone is a function of its osteogenic activity and
blood flow. Since many conditions can alter the degree
of tracer localization, it is particularly important to
correlate the abnormalities in bone scan with detailed
radiographic views of the involved areas and with the
clinical situation to come to an accurate diagnostic
Discussion: Child Abuse Fractures
1. Epiphyseal-Metaphyseal Fractures
Injuries at the epiphyseal-metaphyseal junction are
highly suggestive of abuse. The periosteum
surrounding the growing long bones is thick and tightly
anchored at both ends by heavy extensions into the
epiphyseal cartilages. In contrast, the highly
vascularized, loosely attached young periosteum of the
diaphysis is easily torn from its underlying cortex. The
resultant subperiosteal bleeding lifts the periosteum,
forming layers of periosteal new bone away from the
cortex to form an external shell of new bone.
This extremely strong periosteum that is tightly
anchored by heavy extensions into the epiphyseal
cartilages can easily explain the dynamics of
epiphyseal-metaphyseal fractures. Axial ligament and
periosteal traction or torsion forces are generated by
sudden traction on the extremity, such as occurs when
the arms or legs are pulled or swung violently upward or
forward. This results in the typical traction "corner"
fracture pathognomonic of child abuse. These are
well-visualized in the cases described above.
2. Metaphyseal Fractures
Metaphyseal fractures were first described by Caffey
in 1972, who felt they represented an indirect avulsion
injury to the metaphysis by the pull of the periosteum
when the child was severely shaken. In 1983,
Kleinman and Zito showed these to be transverse
fractures through the metaphysis and only appeared to
be avulsion injuries because of the radiographic
projection views. If the metaphysis is tipped or simply
projected obliquely to the X-ray beam, the margin of the
resultant fragment is projected with a bucket-handle
appearance. If the peripheral fragment is substantially
thicker than the central fragment, and the plane of injury
is viewed tangentially, a corner fracture appearance
results. Note the potential radiographic appearance of
the injuries diagrammed earlier.
View diagram of these injures.
These authors believed that metaphyseal fractures
were most suggestive of abuse. Reed has pointed out
that these metaphyseal fractures can be seen in other
orthopedic conditions, including rickets, scurvy, multiple
congenital contractures, and kinky-hair syndrome.
3. Diaphyseal Fractures
Diaphyseal fractures can be grouped into three
broad categories: 1) Transverse, spiral, and oblique
shaft fractures. 2) Multiple fractures in various stages
of healing. 3) Bony deformity.
A spiral or oblique fracture is produced by a twisting
mechanism, while a transverse fracture is caused by a
Technetium 99 bone scanning has been shown to
be highly sensitive when used to assess skeletal injury,
particularly in occult areas not easily accessible to
clinical examination. The scan is frequently "hot" for
many weeks during healing. The bone scan can be
especially useful in identifying fractures of flat bones,
such as the skull, ribs and scapulae, which may be
missed on radiographic films.
In summary, radiographic findings indicating child
abuse include epiphyseal-metaphyseal fractures, such
as "corner" / "bucket-handle" fractures, and
subperiosteal hematoma bone formation as described
above. Consultation with an experienced radiologist will
often be helpful in determining the etiology of the injury.
1. Black GV. Child abuse fractures. In: Letts RM.
Management of Pediatric Fractures, 1994, New York,
Churchill Livingston, pp. 931-944.
2. Caffey J. On the theory and practice of shaking
infants. Am J Dis Child 1972:124:161.
3. Kleinman PK, Zito JL. Skeletal injury in the
young battered infant: An expanded radiologic
spectrum. Presented to the 26th Annual Meeting of the
Society for Pediatric Radiology. Atlanta, April 1983.
4. Reed MH. Pediatric Skeletal Radiology. 1992,
Baltimore, Williams & Wilkins.
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