Bone of a child (age <18) is cracked or broken.

15% of all injuries in children

Different bone structure than adults thicker periosteum, softer bones

Age and sex related differences

Incomplete fractures Greenstick Torus/buckle fractures

Complete fractures

Closed fracture Open/compound fracture

Hairline fracture

Single fracture

Segmental fracture

Comminuted fracture

Corner or bucket-handle fracture

Physeal fractures

A bend on one side of the bone and a partial fracture on the other side

This fracture occurs at the metaphyseal locations and resemble the torus or base of a pillar in architectural terms.

Acute angulation of the cortex

Fragmentation of the proximal/distal end of long bones (femur>tibia>humerus)

The loose piece appearing at the bone margins as an osseous density paralleling the metaphysis

Characteristic of child abuse-related injuries.

Minimally or undisplaced spiral fractures lower limb bones , usually of the tibia

9 months -3 years

vague symptoms , refusal to bear weight , irritability.

Multiple views. Usually undisplaced. Despite multiple views, no fracture follow up

radiographs ..slight sclerosis and periosteal reaction.

Differential diagnosesFor proximal tibia consider trampoline fracture of proximal tibia

For spiral fractures of femur Non-accidental fractures

SALTER-HARRIS CLASSIFICATION

Mnemonic SALTER I-S = Slip (separated/ straight across) II-A = Above / Away from joint III-L = Lower IV-TE = Through Everything V-R = Rammed (crushed)

Battered child syndrome/shaken infant syndrome/stress-related infant abuse/ non-accidental trauma

Most common cause of serious intracranial injuries in children less than 1 year of age

3rd most common cause of death in children after sudden infant death syndrome and true accidents

Age usually <2 years In children <2 years of age >skeletal survey to

demonstrate other fractures In children >2 years of age > bone scan

Clinical findings Skin burns Bruises Lacerations Hematomas Skeletal trauma in 50-80%

Site(s) Remarks

Distal Femur, distal humerus, wrist, ankle

Metaphyseal corner fractures

Multiple Fractures in different stages of healing

Femur, humerus, tibia Spiral fractures < 1 year of age

Posterior ribs, avulsed spinous processes

Unusual “naturally-occurring” fractures <5years of age

- Multiple 'eggshell' fractures- Occipital impression fractures- Fractures crossing sutures

highly suggestive of childAbuse

Fractures with abundant callous formation

Implies repeated trauma and no immobilization

Metacarpal and metatarsal fractures Unusual “naturally-occurring” fractures <5years of age

Sternal and scapular fracturesVertebral body fractures and subluxations

-do-

Leading cause of morbidity and mortality in infants and children.

Neck muscles are very weak and head is large and heavy in proportion to the rest of the body

Brain is poorly myelinated and is surrounded by larger subarachnoid spaces

Whiplash injury caused by rigorous shaking.

Subdural hemorrhage

Subarachnoid hemorrhage

Epidural hemorrhage (uncommon)

Cerebral edema (focal, multifocal, diffuse)

Acute cerebral contusion

T1WI shows bilateral fluid collections as a result of chronic bilateral subdural hematomas and new subdural hematomas in the right frontal and posterior interhemispheric region.

Second leading cause of death in child abuse

Cause >crushing blow to abdomen (punch, kick)

Age often >2 years

Small bowel and/or gastric rupture

Hematoma of duodenum and/or jejunum

Contusion and/or laceration of lung, pancreas, liver, spleen, kidney

Traumatic pancreatic pseudocyst

Accidental injury Normal periostitis of infancy Osteogenesis imperfecta Congenital insensitivity to pain Infantile cortical hyperostosis Menkes kinky hair syndrome Schmid-type chondrometaphyseal dysplasia Scurvy Congenital syphilitic metaphysitis

Osteogenesis Imperfecta

Menke’s Disease

Metaphyseal Dysplasia

Caffey’s Disease

Salter-Harris Type-I

Fracture through the growth physis, resulting in slippage of the overlying epiphysis.

Femoral epiphysis remains in the acetabulum , while the metaphysis move in an anterior direction with external rotation.

Most common hip disorder in adolescence 11-15 yrs

Obese adolescent black males, M:F 2:1

Symptoms gradual, progressive onset of thigh or knee pain with a painful limp.

1/5 cases involve both hips

Plain Film Projections • Anterior • Frog-leg Lateral

CT May resolve finer anatomy MR • Most sensitive for small changes in soft

tissues

Klein’s Criteria

• Earliest: Widened and irregular growth plate, compared to contralateral hip

Increased lucency medially

• Angulated contour of femoral head, becomes rounded with adaptation

• Periosteal proliferation at inferior, posterior margins and further slippage create “crow’s beak

Klein's Line • Line drawn along superior border of femoral

neck should cross at least a portion of the femoral epiphysis

• Most sensitive indicator of a mild slip on plain film

Capener’s Sign On AP, ischium and femoral head overlap to

yield crescent of double density • SCFE reduces overlap area • Sometimes more sensitive than Klein’s line

alone

Classification Grade I: displacement of epiphysis less than

30% of width of femoral neck

Grade II: slip between 30%-60%

Grade III: includes slips of greater than 60% the width of neck

If undetected, disabling sequelae.

Devastating if missed, essential to recognize

Diagnosis is still most often made on plain film

When SCFE is in question, get a frog leg

Look for Klein’s line and Capener’s sign