Child abuse or copper deficiency? A radiological view.

18 McNeil BJ. A diagnostic strategy using ventilation-perfusion studies in patients suspect for pulmonary embolism. Copper deficiency has been a recognised cause of hypo-chromic, microcytic anaemia and neutropenia in infants for over 30 years.`'~ It also causes skeletal abnormalities and fractures, and recently copper deficiency has been offered to the courts (and given wide publicity) as an explanation of the radiological findings in children whose parents have been charged with abuse. The case of one such child with multiple rib, long bone, and metaphysical fractures was recently heard by the Court of Appeal. In dismissing the appeal the Lord Chief Justice rejected the defence's evidence on copper deficiency and suggested that it actually strengthened the prosecution case. Should copper deficiency be considered in the differential diagnosis of non-accidental injury? The skeletal manifestations ofcopper deficiency occur late and comprise retardation ofbone age, osteoporosis (which is often severe), metaphyseal cupping, increased density of the zone of provisional calcification, and metaphyseal sickle shaped spurs. These changes are distributed symmetrically throughout the skeleton.5 Copper deficiency is rare-only about 100 cases have been reported-and fractures caused by copper deficiency are even rarer: there'have been 16 documented cases, and only five in term infants.3 ' Full term infants are born with high body stores of copper that are sufficient for at least the first six months of life. Modern British infant feeding formulas containing 40 ig copper per 100 ml are not associated with copper deficiency in term infants, and no breast fed infant has ever developed copper deficiency. The five full term infants with fractures were all having an abnormal diet or total parenteral nutrition. Rib fractures have been recorded only in premature infants, and skull fractures have never been described. All the children with fractures had obviously abnormal bones. Metaphyseal fractures are highly suggestive of non-accidental injury and are the most valuable single diagnostic radiographic feature.' They are undoubtedly traumatic: some parents admit to injuring their child, and similar lesions are seen in newborn infants who have suffered a traumatic breech delivery. The new bone formation that accompanies fracture healing is often not present with intra-articular fractures,9 and the fractures themselves often do not produce local pain, swelling, and heat.'lo Those who are unfamiliar with this picture may discount a traumatic origin and ascribe the radiological signs to another cause of metaphyseal abnormalities-such as copper deficiency. The differentiation of metaphyseal abnormalities caused by copper …