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1 Department of Child Health, Cardiff University, Wales College of Medicine,
Academic Centre, Llandough Hospital, Penarth CF64 2XX, Wales, United
Kingdom.
2 Department of Radiology, Cardiff University, Wales College of Medicine, Heath
Hospital, Heath Park, Cardiff CF14 4XN, Wales, United Kingdom.
3 Duthie Library, Cardiff University, Wales College of Medicine, Heath Hospital,
Heath Park, Cardiff CF14 4XN, Wales, United Kingdom.
Received August 5, 2004;
accepted after revision September 9, 2004.
Supported by the National Society for the Prevention of Cruelty to Children
of the United Kingdom.
Abstract
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CONCLUSION. Radiologic dating of fractures is an inexact science. Most radiologists date fractures on the basis of their personal clinical experience, and the literature provides little consistent data to act as a resource. There is an urgent need for research to validate the criteria used in the radiologic dating of fractures in children younger than 5 years.
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Police and lawyers are particularly interested in the timing of injuries in child abuse to identify or exclude potential perpetrators. In the court setting, radiologists are frequently asked to date fractures to narrow down the time of injury. We have conducted what we believe to be the first systematic review of the literature to define the evidence for radiologic dating of fractures in children in the context of child protection.
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All included studies were analyzed using standardized data extraction and critical appraisal forms [17]. Studies were graded for quality on the basis of study design, accurate documentation of the time of injury, and standardized criteria for radiologic dating.
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Two studies defined staging criteria (Table 1). Islam et al. [19] examined 707 radiographs of forearm fractures in 141 children randomly selected over a 4-year period; only 23 were younger than 5 years. All fractures were immobilized with casts. Fractures treated by surgical fixation were excluded. Patients underwent radiography at various times ranging from 0 to 100 days after injury. A pediatric radiologist who was unaware of the time interval after trauma assessed all radiographs. The study defined clear staging criteria that were based on data from the radiology and histology literature (Table 2).
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Using their dating criteria, Islam found that periosteal reaction was not observed on any radiograph obtained before 2 weeks after the injury. However, only 22 patients (most with casts) underwent radiography between 7 and 14 days after the injury. The earliest radiographs appear to have been obtained 7 days after the injury. Periosteal reaction was evident in all 33 patients imaged 4 weeks after injury. Density increased at fracture margins at 2 weeks, with a peak at 4 to 6 weeks in 85% (128/150) of the fractures. No increase in fracture margin sclerosis was seen after 11 weeks. Calcified callus (calcified periosteal reaction) was seen as early as 2 weeks after injury in 15% (18/117) of the fractures and at all fracture sites by 4 weeks. After 10 weeks, 90% (26/29) of the calluses had a density equal to or greater than that of the cortex. At 8 weeks, 50% of the fractures showed evidence of bridging. The earliest remodeling was seen at 4 weeks and was noted in 95% (91/96) from 8 weeks onward.
Yeo and Reed [20] also defined criteria with which to date fractures radiologically, looking only at callus formation. Patients with solitary closed nonpathologic fractures of the femoral shaft were included. All were treated by traction followed by the application of a hip spica cast. Radiographs were obtained as clinically indicated at varying time intervals (Table 1). Three stages of callus formation were defined (Table 2): stage 1, the earliest radiographically visible calcification of callus; stage 2, callus completely bridging the fracture; and stage 3, smooth, homogeneous mature callus in which the fracture line is still visible.
The third included study, conducted in 1979, assessed 23 newborns with fractured clavicles, humeri, and femurs sustained at birth. These were assessed solely for first appearance of calcification at fracture site. The earliest appearance was 7 days after birth; peak calcification was seen 9-10 days after birth; and the latest appearance was 11 days after birth. The numbers included were again very small and differed for each fracture. No details were offered as to how many radiographs were acquired per child and at what time intervals.
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Radiologists usually determine the age of fractures based on clinical experience and guidance offered in textbooks [21]. Unfortunately the terms describing the phases of healing differ between the two included studies that offer criteria [19, 20], and these differ from the terminology in Kleinman's textbook [21] (Table 3). The table in this often-quoted source is derived from the personal clinical experience of the authors and has not been further validated by any primary research (J. F. O'Connor, personal communication, June 2004). It is impossible to assess whether the three sets of criteria are in agreement as to the peak times at which phases of healing occur. A radiologist who regularly reports trauma radiographs, with a documented history for time of injury, can develop expertise in this area over time. However, because the criteria are not standardized or reproducible, less experienced radiologists have little primary evidence on which to base their practice.
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Despite the conflicting conclusions of the included studies, there is agreement that hard callus and early remodeling are seen at 8 weeks in most cases. Early callus was first noted 7 days after injury and was present in 50% by 4 weeks. The variable interval between radiographs in the studies leaves gaps at the most crucial early stages of healing, and time frames may therefore be inaccurate. There is universal agreement that the radiologic features noted are a continuum, with considerable overlap. Larger-scale studies are needed to assess standardized criteria for dating fractures in children younger than 5 years.
The fractures in these studies were all immobilized, which limits its application to dating fractures in child abuse. Many abusive fractures are occult [25, 26], and late presentation allows continued movement, further injury and repetitive fracture, further complicating the dating process. It is frequently stated that fractures heal faster in young children and especially in infants, but as yet, there is no published radiologic evidence to support this statement. It has been noted in adults that healing may be faster with coexistent severe head injury. Perkins and Skirving [27] found that the average femoral fracture healing time was 12.4 weeks in those with a head injury versus 15.7 weeks in control subjects (p < 0.00005). A study by Spencer [28] that included an age range from 4 to 67 years found almost identical changes: 12.4 weeks in the group with a head injury versus 15.2 weeks in the control subjects. Unfortunately, the data for the children were not separated from the data for adults, making it impossible to analyze it for this review. This finding may be relevant in the context of nonaccidental head injury in which fractures coexist in as much as 50% of the cases [29].
Pergolizzi and Oestreich [30] highlighted the importance of familiarity with normal physiologic periosteal reaction in infants younger than 6 months. These infants may show symmetric diaphyseal periosteal reaction, although it may be more prominent on one side [31]. This should not be misinterpreted as a healing fracture.
In 1996, Kleinman et al. [32] mentioned that performing a repeat skeletal survey 2 weeks after the initial survey aided in the dating of fractures in 18% (13/70) of children younger than 3 years. No details were given as to what specific features were used for dating in this study. Bone scans have no place in fracture dating because they show positive results within 7 hr of injury [33] and can continue to show positive results for as long as 1 year.
Digital imaging is rapidly replacing standard techniques in many centers. Although Kleinman et al. [34] found these digital techniques to be comparable to conventional imaging for identifying abusive fractures postmortem in the United States, no assessment of digital radiologic fracture dating has been performed. The direct digital radiography system used in the study by Kleinman et al. differs from the computed digital radiography system more widely used in the United Kingdom. Studies are urgently required to validate dating using both systems if this is to become standard practice.
In conclusion, our analysis showed that the evidence base for current methods of radiologic dating is sparse. Dating of fractures in children is an inexact science. The radiologic features of bone healing are a continuum, with considerable overlap. Radiologic estimates of the time of injury are made in terms of weeks rather than days. It is vital for all investigating agencies to be aware of these broad time frames. However, radiologists can clearly differentiate recent from old fractures. Such differentiation remains valuable in identifying a child who has been subjected to repeated abuse or whose injuries are thus shown to be inconsistent with the history offered.
Our findings have the following four implications for practice: the dating of fractures in children is an inexact science; clinicians must bear this fact in mind when offering time frames of injuries to investigating agencies or courts; periosteal reaction is seen as early as 4 days and is present in at least 50% of the cases by 2 weeks after the injury; and remodeling peaks 8 weeks after injury.
Acknowledgments
We thank our panel of expert reviewers, the Welsh Child Protection
Systematic Review Group: M. Barber, P. Barnes, M. Bhal, J. Bowen, R. Brooks,
A. Butler, S. Datta, R. Frost, C. Graham, M. James-Ellison, N. John, A.
Maddocks, S. Morris, A. Mott, A. Naughton, C. Norton, H. Payne, L. Price, B.
Ranton, P. Thomas, E. Webb, and C. Woolley.
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