You are here » CORE INFO » Reviews » Fractures » What is the evidence for radiological dating of fractures in children? » Results

Results

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 540 studies reviewed, seven studies were included to address the radiological dating of fractures in children 1-7
  • Study designs:
    • 4 cross-sectional 1,3,4,7
    • 1 case series 2,6
    • 1 retrospective cohort 5
  • Age range: 0-17 years
    • 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 ascertained children who had been abused, and the authors felt they could identify the timing of the injury 2,5
    • Halliday et al’s study concluded 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
    • Sanchez et al, studying 16 infants, evaluated callus formation as an indicator of healing 5
  • Three studies defined different radiological criteria for fracture dating, one on immobilised forearm 3, one on femoral fractures 6, and one on all long bones, predominantly upper limb 4
  • Three studies agreed that hard callus and early remodelling 5 is seen at eight weeks in the majority of cases 3,7
  • One of the most recent studies demonstrated that the peak period for a hard callus is at 3 weeks or greater and remodelling at five weeks or greater 4
  • Cumming’s study estimated the earliest calcification at fracture site in 23 newborns, calcified periosteal reaction was noted as early as seven days 1
  • In one study levels of agreement between three radiologists regarding the timing of radiological features was only deemed ‘moderate’, apart from recognition of periosteal reaction 2
  • In another, levels of agreement between three radiologists were high amongst all radiographs, however the presence of a cast limited interpretation for some images 4
  • A study exploring the rate of radiological healing in newborn infants evaluated 131 infants with clavicular fracture aged 0-93 days. A timetable of healing according to standardised criteria was developed 6

 

Summary of the dating characteristics identified

Radiologic feature

Cumming 1979 1

Peak
(range)

Yeo 1994 7

Peak
(range)

Islam 2000 3

Peak
(range)

Halliday 2011 2*

Peak
(range)

Prosser 2012 4

Peak
(range)

Sanchez 2013 5*

Peak (range)

Walters 2014 6

Peak (range)

Fracture gap widening

 

 

4-6 weeks 56%
(2-8 weeks)

Did not assess

Did not assess

 

 

Did not assess

Periosteal reaction presence (Stage 1)

 9-10 days
(7-11 days)

 1.6 weeks
(1-3 weeks)

4-7 weeks 100%
(2 weeks onwards)

(4-11 days)

15-35 days

(5-96 days)

(1-3 weeks)

10 days

(8-14 days)

Marginal sclerosis

 

 

4-6 weeks 85%
(2-11 weeks)

Did not assess

Did not assess

 

 

Did not assess

1st callus

 

 

4-7 weeks 100%
(2 weeks onwards)

(4-11 days)

22-35 days

 (12-66 days)

(3-5 weeks)

Started at 10 days, peaked at 15 days

Callus density > cortex**

 

 

13 weeks 90%
(4 weeks onwards)

**Did not assess, however = density noted

 (16-34 days)

≥ 22 days

(19-96 days)

 

 

Bridging
(Stage 2)

 

2.6 weeks
(1.5-3.7 weeks)

13 weeks 50%
(3 weeks onwards)

Earliest seen at 13 days, present on all films > 20 days

≥ 36 days

(19-300 days)

(7-9 weeks)

Did not assess

Periosteal incorporation

 

 

14 weeks
(7 weeks onwards)

Did not assess

Did not assess

 

 

Did not assess

Remodelling
(Stage 3)

 

8 weeks
(5-11 weeks)

 9 weeks
(4 weeks onwards)

Did not assess

≥ 36 days

(45-421 days)

 

Did not assess

 

    • * drawn from a population of children who were abused, with assumed date of injury

 

With thanks to Dr Kath Halliday for providing original data from her study 2

 

 

Click here to open

References

  1. Cumming WA. Neonatal skeletal fractures. Birth trauma or child abuse? Journal of the Canadian Association of Radiologists. 1979;30(1):30-33 [Pubmed]
  2. Halliday KE, Broderick NJ, Somers JM, Hawkes R. Dating fractures in infants. Clinical Radiology. 2011;66(11):1049-1054 [Pubmed]
  3. 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]
  4. Prosser I, Lawson Z, Evans A, Harrison S, Morris S, Maguire S, Kemp AM. A timetable for the radiologic features of fracture healing in young children. American Journal of Roentgenology. 2012;198(5):1014-1020 [Pubmed]

  5. Sanchez TR, Nguyen H, Palacios W, Doherty M, Coulter K. Retrospective evaluation and dating of non-accidental rib fractures in infants. Clinical Radiology. 2013;68(8):e467-e471 [Pubmed]

  6. Walters MM, Forbes PW, Buonomo C, Kleinman PK. Healing patterns of clavicular birth injuries as a guide to fracture dating in cases of possible infant abuse. Pediatric Radiology. 2014;44(10):1224-1229 [Pubmed]

  7. Yeo LI, Reed MH. Staging of healing of femoral fractures in children. Canadian Association of Radiologists Journal. 1994;45(1):16-19 [Pubmed]

 

^ back to top