Pediatr Radiol (2014) 44:1224–1229
DOI 10.1007/s00247-014-2995-z
ORIGINAL ARTICLE
Healing patterns of clavicular birth injuries as a guide
to fracture dating in cases of possible infant abuse
Michele M. Walters & Peter W. Forbes & Carlo Buonomo &
Paul K. Kleinman
Received: 4 December 2013 / Revised: 17 February 2014 / Accepted: 30 March 2014 / Published online: 29 April 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Background Dating fractures is critical in cases of suspected
infant abuse. There are little scientific data to guide radiolo-
gists, and dating is generally based on personal experience and
conventional wisdom.
Objective Since birth-related clavicular fractures are not
immobilized and their age is known, we propose that an
assessment of these injuries may serve as a guide for dating
inflicted fractures in young infants, acknowledging that pat-
terns observed in the clavicle may not be entirely generaliz-
able to other bones injured in the setting of abuse.
Materials and methods One hundred thirty-one radiographs of
presumed birth-related clavicular fractures in infants between 0
and 3 months of age were reviewed by two pediatric radiolo-
gists with 30 and 15 years’ experience. Readers were asked to
evaluate images based on several parameters of fracture
healing, with a focus on subperiosteal new bone formation
(SPNBF) and callus formation. SPNBF and callus were each
evaluated with regard to presence, thickness and character.
Responses were correlated with known fracture ages.
Results SPNBF was rarely seen in fractures less than 7 days
old and was most often present by 10 days. Callus formation
was rarely seen in fractures less than 9 days old and was most
often present by 15 days. SPNBF thickness increased with
fracture age and the character of SPNBF evolved from single-
layered to solid/multilayered. Callus thickness decreased with
fracture age and callus matrix evolved from soft to intermedi-
ate to hard in character.
Conclusion There is an evolution in clavicular fracture
healing in young infants that follows a predictable pattern.
These findings afford the prospect that predictable patterns of
M. M. Walters (*) : P. W. Forbes : C. Buonomo : P. K. Kleinman
Department of Radiology, Boston Children’s Hospital,
300 Longwood Ave., 02115 Boston, MA, USA
e-mail: michele.walters@childrens.harvard.edu
infant clavicular fracture healing can provide an evidence base
that may be applicable in cases of suspected infant abuse.
Keywords Radiography . Fracture dating . Fracture healing .
Child abuse . Non-accidental trauma . Neonate . Clavicle
Introduction
Accurate dating of fractures is desirable in cases of suspected
infant abuse. Determination of fracture age may support or
call into question the veracity of the history provided to
explain a particular injury [1–3]. Multiple fractures of differ-
ent ages are often seen in the setting of inflicted injury, and
reliable fracture dating may be critical to determine if this
pattern is present [1, 4, 5]. Accurate fracture dating can aid
in the identification and exclusion of potential perpetrators in
the setting of abuse [1]. There are little scientific data available
to guide radiologists, and fracture dating is often based on
personal experience and conventional wisdom [1, 6].
Inflicted skeletal injuries are more common in younger age
groups and most frequent in infants [7–10]. Previous works
have focused on patterns of fracture healing in older children,
rather than the more relevant infant population [11–13]. The
timetable of fracture healing is known to be quite different in
these age groups. Some studies have examined healing pat-
terns in fractures that are immobilized [11–15]. This treatment
renders inferences drawn from these fractures less generaliz-
able to cases of child abuse, since inflicted injuries are often
initially untreated due to delay in diagnosis. In some studies,
fractures were evaluated through cast material, a clear limita-
tion to detailed evaluation of healing patterns [11–15]. Other
studies have focused exclusively on later stages of fracture
healing such as callus formation, excluding earlier
subperiosteal new bone formation (SPNBF) from assessments
[11]. A reliable timetable outlining patterns of fracture healing
Pediatr Radiol (2014) 44:1224–1229
should ideally include expected patterns of development of
SPNBF as well as callus.
The periosteum consists of two layers, an outer fibrous
layer and an inner osteogenic layer adjacent to the bony
cortex. In the setting of fracture, the periosteum is stripped
away from the underlying cortical bone, and contained hem-
orrhage dissects along the bone beneath the osteogenic layer
of the periosteum. Hemorrhage is ultimately replaced by
vascular fibrous tissue and new bone [16]. Radiographically,
subperiosteal new bone may appear as a hazy cortical margin
or a thin layer of bone separated from the original cortex by a
discrete lucent interval [17]. This new bone increases in
thickness with time and may evolve to demonstrate a
lamellated or multilayered configuration.
Callus develops around the ends of a fractured bone by
cellular organization within the fracture hematoma, and ulti-
mately unites the fracture fragments. Fibrovascular tissue
replaces the hematoma with collagen fibers and matrix ele-
ments, which become mineralized and form the woven bone
of the primary callus. This process begins near the fracture
margins and proceeds centrifugally away from the injury site.
Cartilage formation occurs, predominantly at the periphery of
the callus, and conversion to bone occurs through endochon-
dral ossification. Radiographically, callus is initially visible as
faint calcification and referred to as soft, immature or fluffy.
As ossification progresses and callus thickens and develops a
trabecular matrix, it is referred to as hard or mature [16].
With further healing, the SPNBF blends with the callus
forming a firm bony union across the fracture site.
The birth-related clavicular fracture is an appealing surro-
gate for inflicted injury because fracture age at the time of
imaging is known with reasonable certainty. Additionally, this
model affords the study of the patterns of fracture healing in
young infants, the population at greatest risk for a poor out-
come [18]. Clavicular morphology is similar to that of other
tubular bones, and therefore healing patterns may be general-
izable to fractures involving the long bones and ribs in abused
infants. Also, infant clavicular fractures are generally not
immobilized [19], and therefore the spectrum of fracture
healing may be similar to that of abusive fractures in which
treatment is delayed. The purpose of this study was to define
predictable patterns of fracture healing in infants through the
assessment of a large sample of birth-related clavicular inju-
ries to establish an evidence base that can be applied in the
setting of suspected infant abuse.
Materials and methods
Inclusion criteria
A retrospective study of clavicle fractures in infants (0–
3 months) imaged at two tertiary care institutions from 1997
1225
to 2009 was performed. Cases were identified employing an
electronic text search for radiology reports where the follow-
ing phrases appeared: clavicle fracture, birth injury, shoulder
dystocia or large for gestational age. Injuries that were con-
sidered to be birth related were identified through a review of
radiology reports in conjunction with the clinical notes from
the newborn nursery, intensive care unit, primary care visits
and emergency department clinical notes. Infants were ex-
cluded when relation to the time of birth could not be
established with a reasonable degree of certainty. Premature
infants and those with any significant health issue such as
congenital heart disease or sepsis were excluded, as it was felt
that the stress associated with these conditions might affect
observed patterns of fracture healing. Infants with potentially
confounding factors such as skeletal dysplasia or
pseudoarthrosis were also eliminated from consideration. This
electronic search and medical record review yielded 142
cases. Following preliminary evaluation of images, 11 of these
142 cases were eliminated. In four, image quality was felt to
be suboptimal for detailed fracture analysis. In three others, a
fracture could not be confirmed. Concomitant infection was
present in three eliminated cases. Of these, two patients were
septic and concern was raised for osteomyelitis involving the
clavicle based on clinical and imaging findings. The third had
a soft-tissue infection in the supraclavicular region, with a
large, organized collection demonstrated on ultrasound. In
one patient, accidental trauma occurred at home in the neona-
tal period shortly after discharge from the hospital. Thus, it
was not felt that clavicular injury could be tied to the date and
time of birth with an acceptable level of certainty. Following
preliminary image review, a cohort of 131 cases of presumed
birth-related mid shaft clavicle fractures was compiled. In this
cohort, some infants were imaged on more than one occasion
separated by a minimum of 24 h. Ten infants were imaged
twice, three infants were imaged three times, and one infant
was imaged on six separate occasions.
Radiographic analysis
All clavicle fractures were evaluated by two pediatric radiolo-
gists (C.B. and P.K.K.) with 15 and 30 years’ experience at
independent reading periods, respectively. These sessions were
conducted with a facilitator, using a questionnaire that was
completed for each case as readers analyzed specific parameters
of fracture healing. Readers were blinded to infant/fracture age.
Primary focus was placed on the evaluation of SPNBF and
callus formation, as these parameters of healing were felt to be
radiographically distinguishable and important in discerning
age of relatively more recent fractures often seen on presen-
tation in the setting of abuse. Readers were initially trained in
the assessment of these parameters of healing, examining
fractures in various stages of healing with the help of a
facilitator. Cases evaluated during training were not included
1226
Fig. 1 Radiographs of the
clavicle in two different patients
show change in subperiosteal new
bone formation (SPNBF)
thickness and character with
fracture age. a Single-layered
SPNBF in a 10-day-old infant
(arrows). b Solid/multilayered
SPNBF in a 13-day-old infant
(arrows)
in the study group. SPNBF was described as new bone
paralleling the original cortex of the bone with a linear con-
figuration, and characterized as single-layered or solid/
multilayered (Fig. 1). Callus formation was described as min-
eralization first evident as amorphous opacity near the cortical
margins of the fracture, and subsequently progressing centrif-
ugally away from the injury site with a more spherical con-
figuration. Callus was characterized as soft, intermediate or
hard in character, with soft callus having a fluffy, cloud-like
appearance, hard callus demonstrating a solid trabecular ma-
trix and intermediate callus falling between the two (Fig. 2).
SPNBF was evaluated with regard to presence, thickness
and character. Presence of SPNBF was assessed on a four-
point scale, with responses including not present, probably not
present, probably present and present. A designation of “pres-
ent but indistinguishable from callus” was also available to
readers. When this was selected, readers were instructed to
skip detailed analysis of SPNBF and analyze fractures in
terms of callus. SPNBF thickness was evaluated relative to
clavicle shaft width, with choices including <25%, 25–75%
and >75%. SPNBF character was classified by readers as
single-layered or solid/multilayered.
Callus formation was evaluated in terms of presence,
thickness and matrix. Callus presence was classified on a
four-point scale designated as not present, probably not
present, probably present and present. Callus thickness
was assessed relative to clavicle shaft width, with choices
including <50%, 50–100% and >100%. Callus matrix was
classified based on the presence or absence of trabecular
architecture as soft, intermediate or hard. For simplicity,
the four-point scale used to assess presence of SPNBF and
Fig. 2 Radiographs of the clavicle in three different patients show the evolution of callus matrix with fracture age. a Soft callus formation in a 12-day-old
infant. b Intermediate callus formation in a 16-day-old infant. c Hard callus formation in a 29-day-old infant
Pediatr Radiol (2014) 44:1224–1229
callus formation was collapsed to a two-point scale: not
present and present.
Readers were asked to record fracture orientation when
possible (vertical, oblique or comminuted). Fracture margins
were assessed and classified as very indistinct, somewhat indis-
tinct, somewhat defined or well defined. Fracture displacement
was evaluated in terms of percent clavicle shaft width and
designated as non-displaced, 0–50%, 50–100% or >100%
displaced relative to shaft width. Fracture angulation was de-
scribed as not present or mild, moderate or severe angulation.
Statistical methods
Data were entered using Excel and analyzed with SAS version
9.3 (SAS Institute, Inc., Cary, NC). The agreement between
the two readers concerning the presence or absence of SPNBF
and callus was compared using two-by-two tables and com-
puting kappa statistics. ANOVA, t-tests and Kruskal-Wallis
nonparametric tests were used to examine the relationship
between fracture age (continuous) and the levels of SPBNF
thickness (3 levels), SPNBF character (2 levels), callus thick-
ness (3 levels), and callus matrix (3 levels). Logistic regres-
sions were used to model the likelihood of the presence of
SPNBF and callus as fracture age increases.
Results
Fracture ages for the 131 cases ranged from 0 to 93 days
(mean: 13±16 days). Each case was evaluated once by each of
two independent readers, yielding 262 reads.
Pediatr Radiol (2014) 44:1224–1229 1227

Overall, reader agreement regarding presence or absence of

SPNBF was excellent (kappa=0.92). Readers agreed that
SPNBF was present in 68 cases and not present in 58 cases.
In the remaining five cases (4%), reader conclusions regarding
SPNBF were different. Fracture age for the five cases where
readers disagreed ranged from 1 to 9 days old.
For fractures between 0 and 7 days of age (n=59 cases, 118
reads), readers agreed that SPNBF was not present in 54 cases
(92%), and present in two cases (3%). In three cases (5%),
readers came to different conclusions about whether SPNBF
was present. For fractures between 8 and 9 days of age (n=7
cases, 14 reads), readers agreed that SPNBF was not present in
Fig. 4 Change in subperiosteal new bone formation (SPNBF) character
three cases (43%) and present in two cases (29%). There was
with fracture age. SPNBF evolves from single-layered to solid/multilay-
disagreement regarding the other two cases. For fractures ered with fracture age
10 days and older (n=65 cases, 130 reads), SPNBF was not
present in only one read. Callus thickness relative to clavicle shaft width was noted
SPNBF thickness relative to clavicle shaft width increased to decrease with increasing fracture age, although this finding
with fracture age (Kruskal-Wallis P<0.0001) (Fig. 3). The was less robust and not significant for each statistical test
character of SPNBF evolved with fracture age. Single- conducted (mean [SD] days: mild 38 [29]; moderate 28 [21];
layered SPNBF was associated with younger fractures than large 22 [9]; ANOVA P=0.008; Kruskal-Wallis P=0.37)
solid/multilayered SPNBF (mean [SD] days: single-layered (Fig. 5). Callus matrix evolved with fracture age. A soft matrix
7.9 [2.9]; solid/multilayered 18.4 [13.3], Wilcoxon rank-sum was noted in younger fractures, and older fractures demon-
test P<0.0001) (Fig. 4). strated a hard matrix (mean [SD] days: soft 18 [8]; intermedi-
Overall, reader agreement regarding callus presence or ate 25 [10]; hard 42 [26]; Kruskal-Wallis P<0.0001) (Fig. 6).
absence was high (kappa=0.89). Readers agreed that callus Logistic regressions were used to model the presence or
was present in 50 cases and not present in 74 cases. There was absence of SPNBF and callus formation. The SPNBF model
disagreement in seven cases (5%). estimates that SPNBF is present by day eight in 50% of cases.
For fractures between 0 and 8 days of age (n=63 cases, 126 The callus model estimates that callus is present by day 13 in
reads), readers agreed that callus was not present in 100% of 50% of cases (Fig. 7).
cases. For fractures between 9 and 14 days of age (n=26 A statistically significant correlation with fracture age was
cases, 52 reads), readers agreed that callus was not present not found for other variables assessed, including fracture
in ten cases (38%) and present in nine cases (35%). In the orientation, fracture margins, displacement and angulation.
other seven cases (27%), readers disagreed about the presence
of callus. For fractures 15 days and older (n=42 cases, 84
reads), readers agreed that callus was not present in one case Discussion
(2%) and present in 41 cases (98%).
Our data demonstrate an evolution in clavicular fracture
healing in young infants that follows a predictable pattern.

Fig. 3 Change in subperiosteal new bone formation (SPNBF) thickness

is expressed as percent clavicle shaft width as a function of fracture age. Fig. 5 Change in callus thickness is expressed as percent clavicle shaft width
SPNBF increases in thickness with fracture age as a function of fracture age. Callus decreases in thickness with fracture age
1228
Fig. 6 Change in callus matrix with fracture age. Callus matrix evolves
from soft to intermediate to hard in character with fracture age
SPNBF is highly unlikely in fractures less than 7 days old, and
is most often present by 10 days. Subperiosteal new bone
thickness increases with fracture age and its character changes
from single-layered to solid/multilayered. Callus formation is
highly unlikely in fractures less than 9 days old and most often
present by 15 days. Callus thickness decreases with increasing
fracture age and callus matrix evolves from soft to intermedi-
ate to hard in character.
There has been little prior published scientific data on
dating fractures. An early study by Cumming [20] focused
on the highly relevant young infant population, studying
newborns with birth-related clavicle, humerus and femur frac-
tures. This small study was limited to the consideration of
timing of the first appearance of calcification at the injury site,
which varied for the different fracture sites studied. Islam et al.
[12] studied and defined staging criteria for forearm fracture
healing in a large population of children between 1 and
17 years old, excluding the young infant population. In their
study, a large majority of cases were in children older than
4 years of age. Several parameters of fracture healing were
assessed, including SPNBF, callus formation and fracture
Fig. 7 Logistic regression demonstrates the probability of presence of
subperiosteal new bone formation (SPNBF) and callus with fracture age
Pediatr Radiol (2014) 44:1224–1229
margin sclerosis. Later stages of healing were also included
in this analysis: bony bridging, periosteal incorporation and
remodeling. All fractures were studied in casts, limiting osse-
ous detail and reducing motion that might have occurred if the
injuries were not immobilized. Yeo and Reed [11] defined
staging criteria for femoral fractures in a small population of
children from birth to 14 years old, focusing only on callus
formation. These injuries were treated, with traction followed
by the application of a cast.
In more recent work, Halliday et al. [14] assessed param-
eters of healing of long bone fractures in infants investigated
for child abuse. Readers analyzed patterns of soft-tissue swell-
ing, SPNBF, fracture line definition, callus formation, callus
character and endosteal callus formation. The degree of inter-
observer agreement among readers was also evaluated, and
found to be only moderate for all features except SPNBF.
Since the date of injury was ascertained through confession
by perpetrators or the testimony of third parties, it was difficult
to estimate fracture age with a high degree of certainty. As
with several other prior studies, fractures were immobilized
and assessments were limited by the presence of cast material.
In 2011, Malone et al. [15] reported a timetable of fracture
healing derived from traumatic injuries of the radius and tibia. Six
stages of fracture healing were described using a classification
system based on data from combined adult and pediatric studies
of bone healing. The authors did not make a distinction between
SPNBF and callus formation. Fractures were immobilized and
assessments were limited by overlying cast material. This group
found that the healing time of younger individuals (0–1 year) was
significantly shorter than older individuals (1–5 years), and the
mean healing time of upper extremity fractures was shorter than
the mean for lower extremity injuries.
In recent work, Prosser et al. [13] studied six parameters of
fracture healing in accidental long bone fractures in a large
sample of children between 0 and 5 years of age. In this
study, mean patient age was 4.8 years at the time of initial
radiographical assessment with relatively few patients in the
infant age group included. Some fractures underwent manip-
ulation and many were evaluated through cast material. Frac-
tures were designated as acute (<1 week), recent (8–35 days),
or old (>36 days) based on radiographical assessments.
A recent study by Sanchez et al. [21] evaluated patterns of
rib fracture healing in a small sample of infants who had
sustained inflicted injury. Initial and follow-up skeletal sur-
veys were assessed, with a focus on the appearance of the
fracture line and the evolution of callus thickness over time.
Six stages of healing were defined based on these parameters
and a timetable for fracture healing was proposed. The authors
suggested that the measurement of callus thickness specifical-
ly may provide an objective means for estimating rib fracture
age. As with earlier work by Halliday [14], date of injury is
difficult to ascertain with certainty with this study design, and
thus estimation of fracture age may not be entirely accurate.
Pediatr Radiol (2014) 44:1224–1229
In our study we strived to overcome some of the
shortcomings of these earlier reports, but the work has
some limitations, particularly with regard to the use of
retrospective methodology. While our review of medical
records took care to identify any cases of clavicular
fractures that may have occurred after birth, we cannot
entirely exclude that possibility. We studied clavicle and
chest radiographs acquired using routine departmental
technique with a conventional imaging system. While
this approach may have offered less detail than Ameri-
can College of Radiology (ACR) standardized skeletal
survey images [22], we chose only those radiographs
that were deemed of sufficient technical quality to as-
sess the features of fracture healing under study. We
examined the imaging features and chronology of frac-
ture repair in the clavicle. While these healing patterns
may apply to other tubular bones injured in the setting
of abuse, their generalization to all inflicted fractures is
limited. We focused on mid shaft clavicular fractures,
and our findings may not apply to healing patterns of
metaphyseal and physeal injuries. Finally, the chronolo-
gy of fracture healing is known to evolve with age;
therefore, our findings noted in early infancy may not
be applicable to older infants and children.
Our study builds on prior research in this area but is unique
in some respects. We studied a large population of young
infants, the age group most commonly affected by inflicted
injury. We believe that our approach using a specific birth-
related tubular bone fracture affords a greater degree of con-
fidence of actual fracture age than studies of inflicted fractures
that rely upon witnesses or perpetrator confessions. Infant
clavicular fractures are usually not immobilized, as is common
initially with inflicted injuries, and this approach offers dis-
tinct advantages to studies of various accidental fractures that
have been casted. We have focused on the earliest parameters
of fracture healing, with a detailed analysis of the patterns of
development of SPNBF and callus formation.
Conclusion
These findings afford the prospect that the predictable
patterns of infant clavicular fracture healing can provide
an evidence base that may be applicable to cases of
suspected infant abuse. Further work is needed to deter-
mine the generalizability of our results to other bones and
other injury patterns seen in the setting of abuse. Study of
the evolution of fracture healing through later infancy and
early childhood is also needed.
Conflicts of interest None.
1229
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