Long bone asymmetry and hemihypertrophy as a skeletal marker of child abuse

Diaphyseal overgrowth is a well-documented complication of long bone fracture in orthopedic studies, but it is not a condition commonly mentioned in the forensic literature as a possible indicator of child abuse. Here we present an occurrence of humeral hypertrophy associated with a physeal fracture to the left distal humerus in a case of infant child abuse. Humeral overgrowth was present in this infant along with superficial bruising, other humeral fractures, rib fractures, and vertebral injuries consistent with battered child syndrome. In 2002, the humeri, lower ribs, and vertebrae of this infant were examined for evidence of injury by Phillip Walker using gross observations, radiographs, and CT scans. After completion of his case report and before the remains were returned to the Medical Examiner, one of the authors used 3D surface scan imaging to generate digital models of the humeri in order to calculate the volume of each bone for purposes of size comparison. The difference in volume was notable and consistent with other measurements demonstrating hypertrophy of the left humerus. This case report combines the results of these earlier analyses with information drawn from original case files and more recent clinical studies to demonstrate that humeral asymmetry caused by hypertrophy from a fracture can provide relevant evidence of previous injury in cases of child abuse, even when the fracture is no longer visible in radiographs. This study also highlights the utility of combining 3D surface scan imaging with other radiographic methods when conducting medicolegal casework.