Introduction:
Pediatric fractures differ significantly from adult fractures due to the presence of open growth plates (physes), greater cartilage content, and the ability of bones to remodel. Accurate imaging is essential for diagnosis, management, and preventing growth disturbances.
Unique Considerations in Pediatric Fractures:
- Presence of growth plates (physis)
- Thicker periosteum aids healing and stability
- Higher bone elasticity leads to incomplete fractures
- Remodeling potential is significant
- Skeletal maturity assessment may be required
Common Pediatric Fracture Patterns:
| Type | Description |
|---|---|
| Greenstick | Incomplete fracture; cortex broken on one side |
| Torus (buckle) | Cortical buckling due to compression |
| Plastic bowing | Bone bends without cortical break |
| Complete fracture | Transverse, oblique, or spiral |
| Physeal injuries | Classified by Salter-Harris system |
Salter-Harris Classification (Physeal Injuries):
| Type | Description | Imaging |
|---|---|---|
| I | Through physis only | X-ray may appear normal |
| II | Physis + metaphysis | Most common |
| III | Physis + epiphysis | Intra-articular |
| IV | Epiphysis, physis, metaphysis | Risk of growth disturbance |
| V | Compression of physis | Diagnosed retrospectively (growth arrest) |
Imaging Modalities:
🩻 1. X-Ray (First-line tool):
- Standard views: AP and lateral
- Include adjacent joints
- Comparison with opposite limb may help
- Key findings:
- Cortical disruption
- Physeal widening or step-off
- Periosteal reaction (healing phase)
🧠 2. Ultrasound (USG):
- Useful for non-ossified cartilage and epiphyseal injuries
- Detects:
- Joint effusions
- Subtle cortical defects (e.g., clavicle, ribs)
- Radiation-free
💡 3. CT Scan:
- Limited use due to radiation risk
- Used for:
- Complex fractures (e.g., intra-articular, skull, spine)
- Fracture dislocations
- Pre-surgical planning
🧲 4. MRI:
- Excellent for:
- Occult fractures
- Physeal injuries
- Stress fractures
- Bone bruises
- Soft tissue and ligamentous injuries
- No radiation; preferred in recurrent trauma or ambiguous X-rays
☢️ 5. Bone Scintigraphy (rare):
- Detects stress or occult fractures
- May be useful in suspected non-accidental injuries (child abuse)
Special Scenarios:
✅ 1. Non-Accidental Injury (NAI):
- Multiple fractures at different healing stages
- Classic metaphyseal lesions, posterior rib fractures
- Imaging includes:
- Full skeletal survey
- Bone scan/MRI
- Detailed documentation
✅ 2. Growth Plate Injuries:
- Early detection important to prevent growth disturbances
- Follow-up imaging may be needed
✅ 3. Pathologic Fractures:
- Fractures through cysts, tumors, or metabolic bone diseases
Radiologic Signs of Healing:
- Callus formation (visible by 7–10 days)
- Periosteal new bone
- Bridging of fracture line
- Remodeling (faster in younger children)
Conclusion:
Imaging in pediatric fractures must account for skeletal immaturity, growth plates, and remodeling potential. X-ray remains the first-line modality, with MRI and USG playing valuable roles in occult and soft tissue-associated injuries. A tailored approach ensures accurate diagnosis and long-term bone health in children.
