Paediatric Musculoskeletal Trauma and the Radiology of Nonaccidental Injury and Paediatric Factures

Fractures account for up to 25% of all injuries in children, being commoner in boys. The type and distribution of injuries vary throughout childhood. There are significant differences in the type of fractures seen in adults because of the difference in the physiology and anatomy of the developing skeleton. Simplistically, a child's bones are more elastic than those of an adult and there is a greater amount of cartilage in the skeleton including that around the growth plate.

When a force is applied to a bone, it will generate stresses within that bone, which may be compressive, tensile or shearing. These stresses will result in deformity of the bone, which will progress as the stress increases. When the force is removed, the bone may eventually return to normal. However, at some point, namely the yield stress, the bone enters a phase of plastic deformity, resulting in microscopic fractures on the tensile side of the bone. This bone may initially be radiographically normal, but follow-up radiographs may show evidence of a healing periosteal reaction in response to these microfractures. With further increases in the deforming force, the bone's ultimate stress point will be reached and the bone then fractures.

In adults, the yield point and ultimate stress points are very close together, so plastic deformity is rare. In the younger child, the greater degree of elasticity of the bone means that there can be a significant difference between the yield point and ultimate point, with a greater propensity for plastic deformity. Cortical bone will tolerate compressive stresses better than tensile or shearing forces. Consequently, childhood fractures may be complete or partial (incomplete). A complete fracture occurs when there is complete discontinuity between two or more bone fragments. An incomplete fracture involves trauma and damage to the bone, but a portion of the cortex remains intact due to the increased elasticity of the bone.

Greenstick, buckle and plastic bowing fall into the category of incomplete fractures ( Fig. 74.1 ). Fractures may also be classified with regards to the fracture pattern; a simple fracture is where there is only a single fracture line. These fractures can be further described as transverse, oblique or spiral, depending on the appearances of the fracture line with respect to the bone's long axis ( Fig. 74.2 ). A comminuted fracture is where there are several fracture lines, and these include segmental fractures and those with butterfly fragments. Open or compound fractures occur when a wound extends from the skin surface to the fracture. Displacement refers to when there is a space and altered alignment between the fracture fragments. Stress injuries can occur due to repeated forces acting upon the bone, which are less than the force needed to fracture the bone ( Fig. 74.3 ).

Summary Box: Musculoskeletal Trauma

The mainstay of imaging musculoskeletal trauma in children remains plain x-rays. This can be supplemented with computed tomography/magnetic resonance imaging if clinically appropriate.
Fracture patterns differ significantly to adults due to the elasticity of children's bones. Common fractures include buckle, greenstick and plastic bowing.
Growth plate injuries are clinically important and common. The Salter–Harris classification system is used where a higher grading indicates a more severe injury with a higher rate of complications.

For the majority of injuries, a good-quality anteroposterior (AP) and lateral radiograph is the only imaging required. From these projections, the fracture pattern, along with any shortening or angulation, can be determined. Rotation is best assessed from the relative position of the joints above and below the fracture, which should be included on the radiograph as standard practice. Careful inspection of a fracture may allow the mechanism of injury to be determined along with a specific fracture pattern, which may have implications as to the stability and hence help to determine management. For all joint radiographs, a careful inspection of the alignment is necessary to assess for dislocations, which can occur with or without an associated fracture.

Physeal Injuries

A cartilaginous physis (growth plate) occurs between a bone and its epiphysis or apophysis. An epiphysis contributes to longitudinal growth, whereas an apophysis does not. In early childhood, a significant portion of the peripheral epiphysis or apophysis may be cartilaginous, with only an ossified centre, and the cartilaginous component will not be visible on a radiograph. The transitional zone between the physeal cartilage and the metaphyseal portion of the bone, ‘the zone of provisional calcification’, is the weakest point in the growing skeleton. The physeal cartilage is weaker than bone, which, in turn, is weaker than the surrounding ligaments.

Injuries which may result in a ligamental tear or joint dislocation in an adult are more likely to cause a physeal injury or an avulsion injury in a child. Up to 15% of fractures of the tubular bones in children affect the growth plate and the majority of physeal fractures are due to shearing or avulsion stresses. The classification of physeal injuries typically uses the system of Salter and Harris, which separates fractures into five main types ( Figs 74.4 and 74.5 ). For higher grades of injuries, there is an increased likelihood that the growth plate will be damaged, which will result in long-term complications such as malunion, premature fusion (partial or complete bony bar with subsequent growth impairment) and avascular necrosis ( Fig. 74.6 ). The latter is most likely to occur in fractures of the femoral neck, radial neck or scaphoid. Whilst the majority of osseous injuries are clearly shown on standard radiographs, magnetic resonance imaging (MRI) can be used to better visualise the physeal cartilage, nonossified portion of the epiphysis and adjacent supporting ligamentous and tendinous structures ( Fig. 74.7 ).

$Fig. 74.4, Illustration of the Salter–Harris Classification of Fractures. Fracture Type Approximate Incidence Description I—Slipped 5% • Isolated to growth plate with epiphyseal separation. • No adjacent bone fracture • Fracture line passes through hypertrophic layer of physis II—Above 75% • Fracture splits growth plate and extends into metaphysis, separating a small fragment of bone • Often secondary to shearing or avulsive forces • Usually seen in children aged 10–16 III—Below 10% • Fracture line passes through the epiphysis, and then horizontally across the growth plate • Most commonly seen in distal tibia in children aged 10–15 IV—Through 10% • Vertically orientated fracture, involving both epiphysis and metaphysis, and crossing growth plate • Most commonly seen in the distal humerus and tibia V—Ruined <1% • Results from compressive force, crushing the growth plate • Can cause subsequent deformity • Often diagnosed retrospectively when growth arrest is discovered at a later date$

Fig. 74.5, Various Salter–Harris Fractures.

Fig. 74.6, Various Complications of Salter–Harris Fractures.

$Fig. 74.7, (A) Salter–Harris I fracture of the distal right radius. Note widening of the growth plate. (B) Magnetic resonance imaging of the same patient showing abnormal increased signal on the T 2 weighted sequences through the growth plate in keeping with an acute fracture.$

The other site of potential physeal damage is at the musculotendinous insertion into an apophysis, particularly following an avulsion injury. In children, the apophyseal physis is the weakest point of the bone, tendon and muscle interface, and, consequently, severe traction on the muscle will result in avulsion of a bone or cartilaginous fragment. Avulsion injuries are common sports injuries and most usually seen around the pelvis and elbow ( Figs 74.8 and 74.9 ).

Fig. 74.9, Illustration of the common pelvic avulsion sites with the associated muscle attachments

Low-energy repetitive traction forces can result in microtrauma, causing a chronic apophysitis. Around the medial epicondyle of the humerus, this is eponymously called ‘little leaguer's elbow’. Radiographs are usually sufficient to diagnose acute avulsion injuries, providing the avulsed fragment is ossified. MRI or ultrasound can be helpful in demonstrating soft-tissue swelling, effusion and marrow oedema in the more chronic presentations.

The Upper Limb

Shoulder/Humerus

Fractures of the clavicle can occur from either a direct blow, or a fall onto the shoulder or the outstretched arm. Typically, they occur in the middle third, and there is a propensity for greenstick injuries due to the plastic nature of the periosteum. The clavicle is the commonest site of birth-related fracture and is associated with shoulder dystocia and obstetric brachial plexus palsy.

Shoulder dislocation is uncommon younger than 10 years of age, because the presence of the humeral physis appears to be in some way protective. Displacement is typically anterior, and the humeral head lies under the coracoid process on the AP radiograph. On the axial view, the humeral head is displaced anteriorly and no longer covers the glenoid.

Proximal humeral fractures are uncommon, with those involving the physis representing just 3% of such injuries. However, the consequences of fractures here may be significant, because the proximal physis accounts for 80% of longitudinal growth of the humerus. Care must be taken in reviewing the proximal humerus, because the normal growth plate has an irregular contour, which should not be mistaken for a fracture.

Younger than 10 years of age, the fractures are typically metaphyseal, whereas in adolescents, they are usually a Salter–Harris type II fracture. Conversely, the proximal humerus is a relatively common site for pathological fractures, typically through a simple bone cyst, although this can occur at any site. This creates the ‘fallen fragment sign’, due to a piece of cortical bone lying within the fluid-filled cavity ( Fig. 74.10 ).

Elbow

There are six separate ossification centres around the elbow joint which appear and fuse in a relatively predictable temporal sequence. These are shown in Table 74.1 and follow the popular acronym CRITOL. Recognition of this sequence is important in determining the presence and type of any injury. Although some variation in the appearances can be seen, the internal apophysis should always appear before that of the trochlea, and any deviation from this, with a history of trauma, is suspicious for an avulsed or malpositioned internal apophysis ( Fig. 74.11 ).

TABLE 74.1

Ossification Centres Around the Elbow Joint Revised

	Age Range at Which the Ossification Centre Becomes Visible Radiographically (Years)	Age Range at Which They Fuse (Years)
Capitellum	0–2	13–16
Radial head	3–6	13–17
Internal (medial) epicondyle	3–9	Up to 20
Trochlea	7–13	13–16
Olecranon	8–10	13–16
Lateral (external) epicondyle	8–12	13–16

The age at which they appear and then subsequently fuse. In general, it occurs earlier in girls than in boys.

Fig. 74.11, Medial epicondyle epiphysis trapped within the elbow joint following avulsion. (A) Anteroposterior. (B) Lateral view.

A good-quality AP and lateral radiograph is essential for evaluating the elbow joint following trauma, for the important assessment of crucial anatomical landmarks and joint alignment ( Figs 74.12 and 74.13 ). Fracture, haematoma or effusion into the elbow joint will cause capsular distension and elevation of the fat pads overlying it. A visible posterior fat pad should be regarded as pathological due to a potential occult injury, particularly a fracture/dislocation of the radial head or neck or undisplaced supracondylar fracture ( Fig. 74.14 ).

Fig. 74.12, Normal Lateral Film of the Elbow.

$Fig. 74.14, Right radial neck fracture with elevated posterior fat pad in keeping with a joint effusion.$

A visible anterior fat pad may be a normal finding. The absence of any visible fat pad does not exclude the presence of a fracture. The medial and lateral epicondyles are extracapsular and so are not associated with capsular distension.

Supracondylar fractures are the commonest fractures younger than the age of 7 years. The majority are the extension type, with posterior displacement of the distal fracture fragment, typically due to a fall on an outstretched arm. Flexion-type fractures with anterior displacement are due to a direct blow on a flexed elbow and are often unstable ( Fig. 74.15 ).

$Fig. 74.15, (A) Left supracondylar fracture with posterior displacement and a large elbow effusion. (B) Posteriorly displaced supracondylar fracture.$

Complications include nerve entrapment, malunion (leading to either cubitus valgus or varus), osteochondral defects and vascular compromise. The absence of the radial pulse may be an indication for arterial imaging before surgical exploration.

Lateral condylar fractures are due to a varus force on an extended elbow. It is important to realise that this fracture may extend through the unossified portion of the capitellum into the joint space (Salter–Harris type IV). Cross-sectional imaging may be warranted to assess the extent of the fracture line into the unossified cartilage or the articular surface.

Forearm/Wrist/Hand

Radial and ulnar fractures can occur together or in isolation, the radius being the commoner single injury site. Forearm fractures may also occur with dislocation at either the elbow or wrist joint, the so-called Monteggia and Galeazzi fractures (which are rare in children). To avoid missing a dislocation, it is vital that the joints above and below a forearm fracture are visualised properly ( Fig. 74.16 ).

$Fig. 74.16, Monteggia fracture of the left radius and ulna (fractured ulna and dislocated radial head) (A). Galeazzi fracture with fractured distal radius and dislocated ulnar head (B) anteroposterior. (C) Lateral.$

Incomplete buckle fractures of the distal forearm metadiaphysis are common, the mechanism of injury typically being a fall on an outstretched hand. The peak incidence in boys is between 12 and 14 and in girls 10 and 12 years. This corresponds to the adolescent growth spurt and relative weakness of the metadiaphysis (see Fig. 74.1 ).

Carpal bone fractures, of which the commonest is the scaphoid, are often radiologically occult. MRI is useful in confirming the diagnosis of any carpal bone fracture and thus expediating appropriate management. With the scaphoid, the site of injury is more likely to be the distal third of the scaphoid, compared with the waist in adults, and so the risk of vascular compromise is lower in children ( Fig. 74.17 ).

Fig. 74.17, Various Scaphoid Fractures: Normal Radiograph Left Scaphoid.

Metacarpal fractures have an increased incidence in older schoolchildren where the mechanism is usually punching or contact sports. The metacarpal of the little finger is most often injured, with the commonest type of fracture being a Salter–Harris type II.

Phalangeal fractures may occur from direct trauma or as a result of avulsion forces, often associated with hyperextension, and it is important that the avulsed fragment is not overlooked as it may be remote from the fracture site due to tendon retraction. Crush injuries of the phalanges are typically seen in the preschool child from accidental mechanisms such as trapping fingers in a door.

The Lower Limb

Pelvis

A number of classifications of pelvic fractures have been proposed, with the general aim being to predict the degree of morbidity associated with the injury and to try to assess the mechanism and force vectors involved in the causation. An improved understanding of causation helps to plan treatment. In principle, the classification systems all detail the type of fracture and the anatomical sites within the pelvis. Unsurprisingly, the more severe injuries, which result in significant disruption of the pelvis, are associated with greater long-term morbidity. They are generally associated with high-velocity impacts and often occur with injuries in other anatomical areas, particularly the brain.

The least severe fractures are avulsion injuries, which are common in adolescence and are typically the result of athletic activity. These can occur at a number of sites related to muscle attachments (see Fig. 74.9 ).

Standard AP radiographs are usually the initial investigation and are useful in assessing for avulsion injuries. For higher-grade injuries, computed tomography (CT) is a more sensitive investigation and in most circumstances is part of a more general screening of a child following high energy/impact trauma.

Acetabular, Hip and Femur

Acetabular fractures are an uncommon, but significant, injury in childhood because if the triradiate cartilage is involved, subsequent growth and acetabular development may be affected.

Posterior dislocation of the hip is commoner than anterior, and although dislocation in children is less likely to result in acetabular injury, avascular necrosis of the femoral capital epiphysis is a serious potential complication if the femur remains unreduced for more than 24 hours. With dislocations, proper assessment of the acetabular margins is vital to exclude occult fractures and this will be improved using CT or MRI.

Femoral head and neck fractures are relatively uncommon and may be associated with femoral head dislocation. They are classified with reference to their location along the femoral neck: namely, transepiphyseal, transcervical, cervicotrochanteric and intratrochanteric. Complications include osteonecrosis (the occurrence of which is increased the more significant the fracture displacement), premature physeal fusion, varus deformity and nonunion.

Femoral diaphyseal fractures may be associated with significant displacement if the fracture line means that there is unopposed muscle traction of the attached bone fragment. It is vital to check for rotation because this will not be corrected without manipulation. Cross-sectional imaging may be required to assess for the degree of rotation.

Knee

Acute knee trauma is a common childhood occurrence. Studies (which have been validated in paediatrics) have devised rules to determine the need for radiographs within this cohort of patients. Radiographs are only indicated when there is isolated tenderness of the patella and head of the fibula, an inability to flex the knee to 90 degrees or if the patient cannot weight bear. AP and lateral radiographs are standard and the use of the skyline view is arbitrary.

An effusion within the knee joint will outline the suprapatellar region and obliterate fat planes. A horizontal beam lateral film will show a lipohaemarthrosis due to the different densities of fat and blood within the joint. The presence of a lipohaemarthrosis is highly suggestive of an intra-articular injury ( Fig. 74.18 ).

$Fig. 74.18, (A) Lateral computed tomography (CT) image of the knee demonstrates a lipohaemarthrosis. (B) Anteroposterior CT image demonstrates a medial tibial condyle fracture.$

Outside of acute trauma, MRI is the technique of choice when assessing for pathological conditions of the knee because it will provide an assessment of ligaments, tendons, menisci and cartilage. CT is valuable for detecting intra-articular fracture displacement and detached bony fragments.

In younger children, the tensile strength of the anterior cruciate ligament (ACL) is greater than that of the bone, causing avulsion of the tibial spine, as opposed to ACL rupture, which occurs in adolescents and adults. This occurs when there is forced hyperextension and rotation of the knee. The detached bony fragment may be seen on radiographs within the knee joint ( Fig. 74.19 ). Both CT and MRI are more sensitive in assessing the degree of displacement and rotation.

Fig. 74.19, Anteroposterior (A) and lateral (B) radiographs of the right knee demonstrates a bony fragment within the knee joint due to an avulsed tibial spine.

Osteochondral fractures are associated with traumatic lateral dislocation of the patella or axial compressive loading on the femur. Typical sites for injury are the lateral femoral condyle or patella. The fracture is through the subchondral bone and there may be a small bony (loose) fragment within the knee joint.

Osteochondritis dissecans is a defect within the subchondral region of the distal femur, typically occurring on the posterolateral aspect of the medial femoral condyle. Other anatomical sites are the talar dome and capitellum ( Fig. 74.20 ). The full aetiology is unknown, but there is necrosis of the subchondral bone that may be the result of repetitive overloading and microtrauma. On radiographs, there is an oval lucency adjacent to the articular margin. MRI is routinely used to assess for stability of osteochondral defects.

The patella is infrequently fractured in children. However, when fractures occur, the commonest types are comminuted and transverse. Sleeve fractures are avulsion injuries of the inferior pole of the patella with a small amount of detached ossified periosteum but a large amount of unossified cartilage and retinaculum. This may be difficult to detect on standard radiographs because there is only a small flake of detached bone, but it is well shown on MRI.

Recurrent patellar dislocations can occur, predominantly if there is underlying patellofemoral joint instability. This occurs mainly in adolescents and may result in injuries to the patellofemoral ligaments and patellar retinaculum with associated patellar and femoral condylar fractures. Imaging assessment is primarily through MRI.

Tibia/Ankle/Foot

Tibia

The classical toddler's fracture is an undisplaced fracture of the middle/distal tibial diaphysis, which may not be initially visible on the conventional AP and lateral radiographs (being more discernible on oblique views). The toddler's fracture is a cause for a child to be non–weight bearing. If there are no other clinical concerns, follow-up imaging is not routinely indicated, due to radiation dose considerations. However, if repeat imaging is performed, periosteal reaction and sclerosis along the fracture line may become visible after about a week.

Stress fractures of the tibia are generally located in the upper third in children aged around 10 to 15 years and are associated with excessive or continuous physical exercise (see Fig. 74.2 ). Approximately 70% of tibial shaft fractures are isolated, with the remainder also involving the fibula. The tibia shows a reduced tendency to remodel and there may be a risk of varus angulation due to the pull of the long flexors and an intact fibula. Isolated fibular fractures are rare and usually occur from a direct blow. If a proximal fibular fracture occurs, a follow-up ankle x-ray is recommended to exclude a medial malleolar fracture (Maisonneuve fracture) or significant ankle ligament injury as these often occur together.

Ankle

Most ankle fractures are adequately assessed with standard radiographs (i.e. AP, lateral ± mortice view). Some confusion can occur from the numerous accessory ossification centres, which may be visible, particularly adjacent to the malleoli.

Epiphyseal, avulsion, Salter–Harris type I and II fractures of the distal tibia ( Fig. 74.21 ) and osteochondral defects of the talar dome account for the majority of injuries (see Figs 74.5 and 74.20 ). Injuries are usually caused by indirect trauma with the foot being fixed and forced either into dorsiflexion, plantar flexion, eversion, inversion or rotation (external or internal). The physes of the distal tibia and fibula fuse at the same time, initially centrally, followed by medially and then laterally. If only one physis is visible, the suspicion of an epiphyseal injury is raised.

$Fig. 74.21, (A and B) Salter–Harris type II spiral fracture of the distal right tibia.$

Transitional fractures (triplane and juvenile tillaux) occur in adolescence, as the name implies, as the skeleton becomes more mature. Triplane injuries are fractures caused by external rotation which causes the fracture to extend in the axial, sagittal and coronal planes. If the fibula is also fractured, it suggests a more severe rotational force.

Tillaux fractures are Salter–Harris type III fractures of the epiphysis and the unfused anterolateral portion of the distal tibial physis, due to avulsion of the anterior tibiofibular ligament. The lack of a fracture component in the coronal plane distinguishes it from a triplane fracture.

In all Salter–Harris type III and IV fractures, there will be intra-articular extension of the fracture line and any degree of displacement should be properly evaluated with CT. Displacement greater than 2 mm often requires precise surgical reduction and fixation.

Foot

Foot fractures account for less than 10% of paediatric fractures, the majority of which occur in the metatarsals and phalanges, particularly the fifth metatarsal. However, children younger than 5 years have a higher proportion of first metatarsal fractures, of which greenstick and torus are the commonest types. It is important not to confuse the normal apophysis of the fifth metatarsal with a fracture ( Fig. 74.22 ).

$Fig. 74.22, (A) The normal apophysis of the fifth metatarsal, which runs in a longitudinal direction parallel to the metatarsal with adjacent transverse fracture. (B) Transverse fracture of the fifth metatarsal base.$

The calcaneum is the commonest tarsal bone to be fractured, classically as a result of a fall from a height. An extra-articular fracture, which involves the tuberosity and avoids the posterior facet is commoner in the immature skeleton. There is an association with other injuries to the limb. Bohler angle is unreliable younger than the age of 10 years, and a normal Bohler angle does not exclude a fracture. CT is the imaging technique of choice for all suspected tarsal injuries.

Talar fractures are uncommon, because it is believed that the high cartilage to bone ratio in the young child is protective. Displaced fractures of the talar neck carry the risk of avascular necrosis. Isolated fractures of the cuboid, navicular and cuneiforms are rare and tend to be simple avulsions.

Stress fractures in the athletic child may occur in any tarsal or metatarsal bone.

Cervical Spinal Injuries

Paediatric spinal trauma is uncommon, with childhood injuries accounting for less than 10% of reported spinal injuries. Spinal fractures account for no more than 2% of all paediatric fractures, the majority of which are the result of road traffic accidents.

Summary Box: Cervical Spine Injuries

Cervical spine injuries are uncommon but clinically important in children and occur primarily due to road traffic accidents.
Magnetic resonance imaging should be used in children younger than 16 years with any neurological signs of spinal cord injury, otherwise initial assessment is with plain film.
Normal variants are clinically important in the spine with pseudosubluxation of C2/C3 and C3/C4 the most common, up to 4 mm of pseudosubluxation is acceptable.

Cervical spine injuries encompass a range of entities including fractures, ligamentous disruption and spinal cord injury, which can occur in combination or individually ( Figs 74.23 and 74.24 ). The recent NICE guidelines (published in 2016) create a pathway for imaging of spinal trauma and recommend CT cervical spine or plain films, dependent on clinical findings and concordant imaging being carried out.

$Fig. 74.23, (A) Fracture through the bilateral posterior arch of C2 (Hangman fracture). (B and C) Computed tomography in the same patient demonstrating the fracture. (D) Magnetic resonance imaging demonstrating cord oedema inferiorly.$

Fig. 74.24, (A) Normal cervical spine radiograph (note radiopaque sandbags limit detail posteriorly). (B and C) Magnetic resonance imaging cervical spine demonstrates ligamentum flavum disruption at the C6 level in keeping with rupture.

In children, the spinal column has significantly more flexibility than the spinal cord. Consequently, severe flexion extension injuries may not result in a fracture or ligamental disruption but will cause significant spinal cord injury. The term ‘spinal cord injury without radiographic abnormality’ (SCIWORA) was described. The increased use of MRI has been able to demonstrate abnormal cord findings in these patients. However, there are a small group of patients where even the MRI is normal despite clinical evidence of cord injury and damage.

It is important that normal anatomical variations are not misinterpreted as possible injuries. The commonest variant is pseudosubluxation at the C2/C3 and C3/C4 levels. Pseudosubluxation of up to 4 mm is acceptable. A line connecting the anterior aspects of the spinous processes on the lateral radiograph (spinolaminar junction) of C1 to C3 should pass within 2 mm of the spinolaminar junction of C2 ( Fig. 74.25 ).

Fig. 74.25, (A and B) A Pseudosubluxation of C2 upon C3. In the same patient, extension view shows normal anterior alignment.

When the C2 spinolaminar junction lies 2 mm or more behind this line, then the possibility of a fracture or true subluxation is raised. On an open mouth view, a pseudo-Jefferson fracture may be observed due to ossification of the lateral mass of C1 exceeding that of C2, so that they appear to overhang the axis by up to 6 mm. Pseudo anterior wedging of the vertebral bodies of up to 3 mm can be a normal variation and is particularly common at the C3 level.

Unfused apophyses, ossification centres and a variety of normal variants may cause some confusion in the spine, and careful assessment is required to differentiate these entities from fractures.

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