The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.
- Of the 490 studies reviewed, four studies were included to address the radiological dating of fractures in children 1-4
- Study designs:
- 3 cross-sectional 1,3,4
- 1 case series 2
- Total data: 290 fractures to 220 children
- Age range: 0-17 years, 87 children were less than five years old
- Two studies found no correlation between the age of the child and fracture dating 1,3
- Gender: two studies found no correlation between gender and the dating of fractures 1,3
- No study addressed fracture dating in disabled children
- No study addressed the influence of ethnicity and socio-economic group
- Two studies defined different radiological criteria for fracture dating, one on immobilised forearm and one on femoral fractures 3,4
- Cumming’s study estimated the earliest calcification at fracture site in 23 newborns 1
- Halliday et al’s study exclusively included children with abusive fractures, where they believed that they knew the timing of the injury. They conclude that if there is no subperiosteal new bone formation (SPNBF) on x-ray, then the fracture is likely to be less than 11 days old 2
Summary of the dating characteristics identified
|
Radiologic feature |
Cumming 19791 Peak |
Halliday 20112 ** Peak |
Islam 20003 Peak |
Yeo 19944 Peak |
|
Fracture gap widening |
Did not assess |
4-6 weeks 56% |
||
|
Periosteal reaction presence (Stage 1) |
9-10 days |
(4-11 days) |
4-7 weeks 100% |
1.6 weeks |
|
Marginal sclerosis |
Did not assess |
4-6 weeks 85% |
||
|
1st callus |
(4-11 days) |
4-7 weeks 100% |
||
|
Callus density > cortex* |
|
*Did not assess, however = density noted (16-34 days) |
13 weeks 90% |
|
|
Bridging |
Earliest seen at 13 days, present on all films > 20 days |
13 weeks 50% |
2.6 weeks |
|
|
Periosteal incorporation |
Did not assess |
14 weeks |
|
|
|
Remodelling |
Did not assess |
9 weeks |
8 weeks |
- Two studies agreed that hard callus and early remodelling is seen at eight weeks in the majority of cases 3,4
- In Cumming’s study, early callus (calcified periosteal reaction) was noted as early as seven days 1
- Levels of agreement between three radiologists regarding the timing of radiological features was only deemed ‘moderate’, apart from recognition of periosteal reaction 2
- **With thanks to Dr Kath Halliday for providing original data from her study 2
References
- Cumming WA. Neonatal skeletal fractures. Birth trauma or child abuse? Journal of the Canadian Association of Radiologists. 1979;30(1):30-33 [Pubmed]
- Halliday KE, Broderick NJ, Somers JM, Hawkes R. Dating fractures in infants. Clinical Radiology. 2011;66(11):1049-1054 [Pubmed]
- Islam O, Sobeleski D, Symons S, Davidson LK, Ashworth MA, Babyn P. Development and duration of radiographic signs of bone healing in children. American Journal of Roentgenology. 2000;175(1):75-78 [Pubmed]
- Yeo LI, Reed MH. Staging of healing of femoral fractures in children. Canadian Association of Radiologists Journal. 1994;45(1):16-19 [Pubmed]