Pediatric Imaging

Prosser et al.
Radiologic Dating of Pediatric Fractures

Review
Ingrid Prosser1
Sabine Maguire1
How Old Is This Fracture?
Sara K. Harrison2 Radiologic Dating of Fractures in
Mala Mann3
Jonathan R. Sibert1
Alison M. Kemp1
Children: A Systematic Review
Welsh Child Protection Systematic
American Journal of Roentgenology 2005.184:1282-1286.

OBJECTIVE. We conducted a systematic review of the literature to define the evidence

Review Group for radiologic dating of fractures in children in the context of child protection.
Prosser I, Maguire S, Harrison SK, Mann M, Sibert JR, Kemp AM

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.

ractures occur in up to 52% of [10], Cumulative Index to Nursing and Allied

F child abuse cases [1, 2]. In con-

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.
1Department of Child Health, Cardiff University, Wales
College of Medicine, Academic Centre, Llandough
Hospital, Penarth CF64 2XX, Wales, United Kingdom.
Address correspondence to A. M. Kemp.
2Department of Radiology, Cardiff University, Wales
College of Medicine, Heath Hospital, Heath Park, Cardiff
CF14 4XN, Wales, United Kingdom.
3DuthieLibrary, Cardiff University, Wales College of
Medicine, Heath Hospital, Heath Park, Cardiff CF14 4XN,
Wales, United Kingdom.
AJR 2005;184:1282–1286
0361–803X/05/1844–1282
© American Roentgen Ray Society
trast to accidental fractures, most
abusive fractures occur in chil-
dren younger than 3 years; 80% of such frac-
tures occur in children younger than 18
months [3]. Abusive fractures may be multi-
ple and of different ages [4, 5], a point that
can only be determined from their dating.
Dating fractures may also highlight inconsis-
tencies between the timing of an injury and
the history given, thus aiding in the diagnosis
of child abuse [6].
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.
Materials and Methods
We performed an all-language literature search
of original articles published from 1966 through
March 2004 as shown in Figure 1. We searched the
Applied Social Science Index and Abstracts (AS-
SIA) [7], CareData [8], MEDLINE [9], Child Data
Health Literature (CINAHL) [11], EMBASE [12],
PsychINFO [13], System for Information on Grey
Literature in Europe (SIGLE) [14], Social Science
Citation Index [15], and Turning Research into
Practice (TRIP) [16] databases. In addition, we per-
formed an appropriate hand-search of literature pub-
lished from 1947 to 23rd February 2004. Key words
used in our search are listed in Appendix 1. Each ar-
ticle underwent two independent reviews by mem-
bers of a group of 27 specialist reviewers including
pediatricians, pediatric radiologists, and orthopedic
surgeons, among other child health professionals
with expertise in child protection. A third review
was performed if there was disagreement among the
initial reviewers. We included primary research ad-
dressing the question of radiologically dating frac-
tures in children younger than 17 years. Studies
were excluded if they were review articles, consen-
sus statements, or expert opinions; if details on chil-
dren could not be extracted from mixed-age data; if
the criteria for dating were not detailed; or if under-
lying bone disease was present.
All included studies were analyzed using stan-
dardized 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 ra-
diologic dating.

1282 AJR:184, April 2005

 Radiologic Dating of Pediatric Fractures

Results
Figure 1 summarizes the total number of
studies identified and reviewed. Three studies
met the criteria for inclusion [18–20], reflect-
ing data on 189 children, 56 of whom were
younger than 5 years.
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 im-
mobilized with casts. Fractures treated by
surgical fixation were excluded. Patients un-
derwent radiography at various times ranging
from 0 to 100 days after injury. A pediatric ra-
diologist who was unaware of the time inter-
val after trauma assessed all radiographs. The
study defined clear staging criteria that were
based on data from the radiology and histol-
ogy literature (Table 2).
Using their dating criteria, Islam found that
American Journal of Roentgenology 2005.184:1282-1286.
appear to have been obtained 7 days after the in-
jury. Periosteal reaction was evident in all 33 pa-
tients 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 sclero-
sis 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. Af-
ter 10 weeks, 90% (26/29) of the calluses had a
density equal to or greater than that of the cor-
tex. 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
calcification of callus; stage 2, callus com-
pletely 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 ap-
pearance 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 radio-
graphs were acquired per child and at what
time intervals.
Discussion
Despite didactic statements in textbooks as
to the dating of fractures in children, there is

periosteal reaction was not observed on any ra- followed by the application of a hip spica cast. a disappointing lack of primary evidence on
diograph obtained before 2 weeks after the in- Radiographs were obtained as clinically indi- which to base dating [21]. Given the high
jury. However, only 22 patients (most with cated at varying time intervals (Table 1). Three prevalence of abusive fractures in infants and
casts) underwent radiography between 7 and 14 stages of callus formation were defined (Table toddlers, and to a lesser extent in preschool
days after the injury. The earliest radiographs 2): stage 1, the earliest radiographically visible children [1, 2, 5, 22–24], it is particularly
worrying that the two larger studies only in-
cluded 33 children in this age group. Other
limitations of the included studies are the
variation of intervals between radiographs
Hand-search of all articles (especially at the early stages of healing) and
MEDLINE 1966–2004
CareData 1970–2004
Hand-search of text books identified from other sources the different numbers of radiographs per frac-
EMBASE 1980–2004 ture (Table 1). The presence of casts, un-
SIGLE 1980–2004
Social Sciences Citation 1981–2004 avoidably, impaired the detection of subtle
CINAHL
ASSIA
1982–2004
1987–2004
radiographic signs. In addition, Yeo and Reed
ISI Proceedings 1990–2004 [20] and Islam et al. [19] chose different bones
Child Data 1996–2004
TRIP database 1997–2004 to study, femur and forearm, respectively,
which may have different healing rates, but
published evidence is lacking in this area.
Radiologists usually determine the age of
fractures based on clinical experience and
guidance offered in textbooks [21]. Unfortu-
Scanned total 1,556 titles and abstracts for duplicates and relevancy
nately the terms describing the phases of heal-
ing 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
399 reviewed
source is derived from the personal clinical
Third Review
experience of the authors and has not been
Translated
146 22 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
Included in analysis
3
peak times at which phases of healing occur. A
radiologist who regularly reports trauma radio-
graphs, with a documented history for time of
injury, can develop expertise in this area over
Fig. 1.—Chart displays our search strategy for articles on radiologic dating of fractures in children. time. However, because the criteria are not

AJR:184, April 2005 1283

 Prosser et al.

TABLE 1 Key Features of Included Studies

Mean No. of
Total No. of
Radiographs Number and Site
Author (year) Study Type Children Age Range Association of Healing With Age/Sex
per Child of Fractures
(no. < 5 yr)
(range)
Islam 2000 [19] Longitudinal 141 (23) 3.7 (2–8) 1–17 years (mean, 8 yr) No association (chi square) 131 fractured radii,
74 fractured ulnae
Yeo 1994 [20] Longitudinal 25 (10) 9 (6–17) Birth–14 yr No association (multiple regression analysis and 25 fractured femora
Student's t test)
Cumming 1979 Longitudinal 23 (23) 1 Birth–11 days N/A 10 clavicles, 6 humeri,
[18] 7 femora
Note.—N/A = not applicable.

standardized or reproducible, less experienced
radiologists have little primary evidence on
which to base their practice.
Despite the conflicting conclusions of the in-
cluded studies, there is agreement that hard cal-
lus and early remodeling are seen at 8 weeks in
most cases. Early callus was first noted 7 days
American Journal of Roentgenology 2005.184:1282-1286.
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 there-
fore be inaccurate. There is universal agreement
that the radiologic features noted are a contin-
uum, 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 im-
mobilized, which limits its application to dat-
ing fractures in child abuse. Many abusive
fractures are occult [25, 26], and late presen-

tation allows continued movement, further in-

jury and repetitive fracture, further
complicating the dating process. It is frequently
TABLE 2 Radiologic Features of Healing in Three Studies Included in Analysis
stated that fractures heal faster in young chil-
Islam 2000 [19] Yeo 1994 [20] Cumming 1979 [18] dren and especially in infants, but as yet, there
Radiologic Feature Peak Peak Peak is no published radiologic evidence to support
(range) (range) (range)
this statement. It has been noted in adults that
Fracture gap widening 4–6 wk, 56% healing may be faster with coexistent severe
(2–8) head injury. Perkins and Skirving [27] found
Periosteal reaction 4–7 wk, 100% 1.6 wk 9–10 days that the average femoral fracture healing time
(stage 1) (2 wk onward) (1–3 wk) (7–11 days) was 12.4 weeks in those with a head injury
Marginal sclerosis 4–6 wk, 85% versus 15.7 weeks in control subjects (p <
(2–11) 0.00005). A study by Spencer [28] that in-
1st callus 4–7 wk, 100% cluded an age range from 4 to 67 years found
(2 wk onward) almost identical changes: 12.4 weeks in the
Callus density > cortex density 13 wk, 90% group with a head injury versus 15.2 weeks in
( 4 wk onward) the control subjects. Unfortunately, the data
Bridging 13 wk, 50% 2.6 wk for the children were not separated from the
(stage 2) (3 wk onward 10) (1.5–3.7 wk) data for adults, making it impossible to ana-
Periosteal incorporation 14 wk lyze it for this review. This finding may be
(7 wk onward) relevant in the context of nonaccidental head
Remodeling 9 wk 8 wk injury in which fractures coexist in as much as
(stage 3) (4 wk onward) (5–11 wk) 50% of the cases [29].
Pergolizzi and Oestreich [30] highlighted
the importance of familiarity with normal
TABLE 3 Timetable of Radiologic Changes in Children’s Fractures physiologic periosteal reaction in infants
younger than 6 months. These infants may
Category Early Peak Late show symmetric diaphyseal periosteal reac-
Resolution of soft tissues 2–5 days 4–10 days 10–21 days tion, although it may be more prominent on
SPNBF 4–10 days 10–14 days 14–21 days one side [31]. This should not be misinter-
preted as a healing fracture.
Loss of fracture line definition 10–14 days 14–21 days
In 1996, Kleinman et al. [32] mentioned
Soft callus 10–14 days 14–21 days that performing a repeat skeletal survey 2
Hard callus 14–21 days 21–42 days 42–90 days weeks after the initial survey aided in the dat-
Remodeling 3 mo 1 yr 2 yr to physeal closure ing of fractures in 18% (13/70) of children
Note.—Adapted from [21, 35] with permission. Repetitive injuries may prolong categories 1, 2, 5, and 6. SPNBF younger than 3 years. No details were given
= subperiosteal new bone formation. as to what specific features were used for dat-

1284 AJR:184, April 2005


ing in this study. Bone scans have no place in
fracture dating because they show positive re-
sults within 7 hr of injury [33] and can continue
to show positive results for as long as 1 year.
Digital imaging is rapidly replacing stan-
dard techniques in many centers. Although
Kleinman et al. [34] found these digital tech-
niques to be comparable to conventional
imaging for identifying abusive fractures
postmortem in the United States, no assess-
ment of digital radiologic fracture dating has
been performed. The direct digital radiogra-
phy system used in the study by Kleinman et
al. differs from the computed digital radiogra-
phy 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 radio-
logic dating is sparse. Dating of fractures in
American Journal of Roentgenology 2005.184:1282-1286.
children is an inexact science. The radiologic
features of bone healing are a continuum,
with considerable overlap. Radiologic esti-
mates of the time of injury are made in terms
of weeks rather than days. It is vital for all in-
vestigating agencies to be aware of these
broad time frames. However, radiologists can
clearly differentiate recent from old fractures.
Such differentiation remains valuable in iden-
tifying a child who has been subjected to re-
peated abuse or whose injuries are thus shown
to be inconsistent with the history offered.
Our findings have the following four im-
plications 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 remod-
eling peaks 8 weeks after injury.
Acknowledgments
We thank our panel of expert reviewers,
the Welsh Child Protection Systematic Re-
view Group: M. Barber, P. Barnes, M.
Bhal, J. Bowen, R. Brooks, A. Butler, S.
Datta, R. Frost, C. Graham, M. James-El-
lison, N. John, A. Maddocks, S. Morris, A.
Mott, A. Naughton, C. Norton, H. Payne,
AJR:184, April 2005
Radiologic Dating of Pediatric Fractures
L. Price, B. Ranton, P. Thomas, E. Webb,
and C. Woolley.
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Appendix 1 appears on next page
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 Prosser et al.

APPENDIX 1. Keywords and Phrases Used for the Fracture Dating Review
1. child abuse.mp. 21. (corner fractur: or bucket handle fractur:).mp.
2. child protection.mp. 22. metaphyseal chip fractur:.mp.
3. (battered child or shaken baby or battered baby).mp. 23. classic metaphyseal lesion:.mp.
4. 1 or 2 or 3 24. or/13-23
5. child:.mp. 25. (investigat: adj3 fract:).mp.
6. non-accidental injur.mp. 26. (radiolog: adj3 fractur:).mp.
7. non-accidental trauma.mp. 27. (roentgen: adj3 fract:).mp.
8. (non-accidental: and injur:).mp. 28. skeletal survey.mp.
9. soft tissue injur:.mp. 29. bone scan:.mp.
10. physical abuse.mp. 30. Isotope Bone Scan:.mp.
11. (or/6-10) and 5 31. Radionuclide.mp.
12. 4 or 11 32. Scintigraphy.mp.
13. fractur:.mp. 33. ((paediatric or pediatric) adj3 radiolog:).mp.
14. rib fractur:.mp. 34. ((paediatric or pediatric) adj3 nuclear medicine).mp.
15. skull fractur:.mp. 35. (ag: adj3 fractur:).mp.
16. femoral fractur:.mp. 36. ((dating or date) adj3 fractur:).mp.
17. humeral fractur:.mp. 37. (pattern: adj3 fractur:).mp.
18. pelvic fractur:.mp. 38. (heal: adj3 fractur:).mp.
19. spiral fractur:.mp. 39. (timing adj3 healing).mp.
20. metaphyseal fractur:.mp.
American Journal of Roentgenology 2005.184:1282-1286.

1286 AJR:184, April 2005