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Stress Injuries of Bone

KEY FACTS Terminology Fatigue fracture: Fracture due to abnormal stresses applied (over time) to normal bone Insufficiency fracture: Fracture due to normal stresses applied to abnormal bone Stress response/reaction: Result of stresses upon bone prior to development of macroscopic fracture Chronic physeal stress injury: Repetitive stress to growth plate interrupts normal endochondral ossification Imaging Stress injury of formed bone Periosteal new bone ± transversely oriented lucent…

Other Fractures of Child Abuse

KEY FACTS Imaging High specificity for child abuse Classic metaphyseal lesions, posterior rib fractures Scapular fractures – Transverse or oblique fractures of mid acromion process most common – Acromion tip fracture mimics ossification center Sternal fractures – Linear lucency or buckling of anterior cortex – Widened sternal synchondrosis or malalignment of sternal segments Spinous process fractures – Cartilage/bone avulsion at interspinous ligamentous attachment due to hyperflexion…

Child Abuse, Metaphyseal Fractures

KEY FACTS Terminology Classic metaphyseal lesion (CML) or metaphyseal corner fracture: Transverse fracture of subphyseal metaphysis that undercuts subperiosteal bone collar peripherally Fracture of infants with high specificity for child abuse Imaging Most common at distal femur, proximal & distal tibia Radiographic appearance Acute fractures subtle, often difficult to identify initially – Triangular fragment at metaphyseal corner when x-ray beam perpendicular to bone long axis –…

Incomplete Fractures

KEY FACTS Terminology Incomplete fracture: Macroscopic fracture line does not traverse entire bony diameter Pediatric bones more elastic than adult bones Greater propensity to bow or bend before breaking Buckle fracture: Focal outward bulge of cortex (without frank interruption) on compression side; cortex usually intact on tension side Plastic deformation: Smooth but accentuated bending of shaft without visible fracture line Greenstick fracture: Discrete fracture line on…

Apophyseal Injuries

KEY FACTS Terminology Apophysis: Nonarticular secondary center of ossification that serves as attachment site for muscle or tendon Acute injury: Avulsion fracture of osseous &/or cartilaginous apophysis through subjacent physis Chronic injury: Repetitive submaximal tensile forces (avulsive microtrauma) exceed rate of repair, leading to local growth plate disturbance (± symptoms) Imaging Acute injury: Displaced apophyseal ossification center Chronic injury: Mild soft tissue swelling with ossific irregularity…

Physeal Fractures

KEY FACTS Terminology Fracture of immature skeleton involving cartilaginous primary growth plate (physis) Imaging Most fractures detected & managed by radiographs alone Widening or interruption of normally uniform undulating lucent physis Translation &/or angulation of bony fragment adjacent to physis with overlying soft tissue swelling Persistent physeal widening > 3 mm post reduction suggests tissue entrapment requiring open reduction CT: Helps evaluate comminution, displacement, articular surface…

VACTERL Association

KEY FACTS Terminology Nonrandom association of anomalies involving multiple organ systems V ertebral/vascular A nal atresia/auricular C ardiac T racheoesophageal fistula E sophageal atresia R enal/radial ray/rib L imb VACTERL association diagnosed when ≥ 3 of above malformations present; causative gene unknown Imaging Actively seek other features of VACTERL association when 1-2 components present Initial imaging in suspected cases: Radiographs & US Radiographs: Spine & limbs…

Approach to Pediatric Musculoskeletal System

Imaging Modalities Radiography Although there have been great advances in imaging technology, radiographs (i.e., x-rays or plain films) remain the most important imaging test in most circumstances of suspected musculoskeletal pathology. Most studies will require 2-3 views to adequately image the site of interest. Each of these views is typically obtained with different patient positioning &/or projection of the x-ray beam to analyze different components of…

Torsion of Testicular Appendage

KEY FACTS Terminology Definition Spontaneous twisting of pedunculated vestigial remnant along testicle or epididymis causing ischemia & pain Synonyms Twisted appendage, torsed appendix testis, torsion of appendix epididymis, appendiceal torsion Imaging US with Doppler best imaging modality Appendage size best indicator of torsion (> 5-6 mm acutely) Spherical shape suggests swelling (normally vermiform) Duration of symptoms determines echogenicity < 24 hours: Hypoechoic with salt & pepper…