Final Pr. ID: Poster #: EDU-052
Stress injuries occur when normal bone is subjected to chronic and repeated mechanical loading. Children are at particularly increased risk for these types of injuries compared to adults, due to weaker chondro-osseous junctions, increased physical activity, less muscle mass, narrower bones with thinner cortices, hormonal changes, and decreased mineral content of bones.
Pediatric stress injuries consist of physeal and apophyseal stress injuries and stress fractures. When the primary physes of the long bones sustain repetitive workloads, endochondral ossification is impeded, and unmineralized cartilage extends into the metaphysis. Such repetitive workloads also affect associated apophyses, leading to chondrocyte proliferation, hypertrophy, and inflammation. Stress fractures, also known as fatigue fractures, occur when bone remodeling is given insufficient time to repair “micro-trauma” damage and additional mechanical loading cycles enable damage to accumulate in the bone, ultimately leading to a fracture.
This educational exhibit will review the imaging findings associated with stress injuries of the axial and appendicular skeleton commonly seen in older children and adolescents. The exhibit will draw on case examples of children participating in a wide range of activities to illustrate the range of stress injuries in the pediatric population and their diagnostic findings, including cheerleading, dancing, baseball pitching, climbing, and even bowling and competitive yoga.
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Authors: Ku Alexei , Schmitz Kelli
Warner Christopher, Maguire Sabine, Miller Angie, Trefan Laszlo, Fadell Michael
Final Pr. ID: Poster #: SCI-057
Fractures are a common manifestation of physical child abuse, and when present can have considerable bearing on the legal process. Although the timing of skeletal injury and healing is of great importance in forensic cases, the dating of fractures in the age group in which fractures from physical abuse most frequently occur is largely based on the radiologist’s personal experience as opposed to primary research. A full understanding of the radiological features of healing in infant fractures will enhance the assessment of fracture dating in cases where the time of injury is unknown, such as suspected abuse. The objective of this study was to describe the timing of fracture healing in infants using previously defined radiographic signs of fracture healing. Read More
Authors: Warner Christopher , Maguire Sabine , Miller Angie , Trefan Laszlo , Fadell Michael
Keywords: Healing Fracture, Fracture Healing, Non Accidental Trauma, Abuse, Long Bone
Xue Christine, Nowrangi Rajeev, Smith John, Acharya Patricia
Final Pr. ID: Paper #: 021
To assess whether a convolutional neural network (CNN) can be trained via transfer learning to accurately diagnose metaphyseal corner fractures on long bone radiographs by comparing its performance to that of a board-certified pediatric radiologist. Secondary endpoints will include the ability of the CNN to detect the type of long bone presented on the radiograph as well as identify the chronicity of the fracture. Read More
Authors: Xue Christine , Nowrangi Rajeev , Smith John , Acharya Patricia
Keywords: AI, Nonaccidental Trauma, metaphyseal corner fractures
Final Pr. ID: Poster #: EDU-055
The purpose of the exhibit is: 1. Illustrate the presence of multiple and accessory ossification centers about the hip that can make it challenging to diagnosis fractures on radiographs in adolescence. 2. Demonstrate that posterior acetabular fractures are typically hidden behind the femoral head on radiographs. 3. Review variant os acetabuli that are commonly encountered in patients with hip pain and demonstrate that the orientation of the fragments compared with posterior acetabular fractures can help to make a distinction. 4. Highlight that a complete pelvis radiograph (AP or AP/Frog leg lateral) in trauma patients or hip pain NOS can aid in the detection of fractures and assess for asymmetry of normal variants. Read More
Authors: Boyd Kevin , Thakrar Pooja
Keywords: Acetabular Fractures, Pediatric Hip, Hip variant
Yacoub Daniel, Wang Kuan Chung, Shah Prakeshkumar, Moineddin Rahim, Doria Andrea
Final Pr. ID: Poster #: SCI-063
Increased fracture risk is a complication that occurs in the context of primary bone diseases such as osteogenesis imperfecta (OI). Despite being considered as the reference-standard, the use of dual-energy X-ray absorptiometry (DXA) to evaluate fragility fractures in OI has not been validated by prior systemic review. Identifying patients at greatest risk for bone fragility fractures and determining skeletal health markers that can monitor bone mass concerning response to bone-active treatments are important issues for clinicians. In this systematic review we assessed the clinical utility of DXA for evaluating osteoporotic bone in OI pediatric patients according to the U.S. Preventive Services Task Force guidelines. Read More
Authors: Yacoub Daniel , Wang Kuan Chung , Shah Prakeshkumar , Moineddin Rahim , Doria Andrea
Keywords: Dual-energy X-ray absorptiometry (DXA), Osteogenesis imperfecta, Systematic review, Fracture, Clinimetric property
Sharp Paige, Braithwaite Kiery, Marshall Kelley
Final Pr. ID: Poster #: EDU-066
The coracoid process serves as a crucial anchor for multiple tendon and ligamentous attachments in the shoulder. While glenohumeral and labral pathology are more commonly implicated in shoulder injuries, the coracoid process can also be a primary pain generator within the shoulder. This educational poster will address normal coracoid anatomy and development, as well as pathologic conditions affecting the coracoid in the pediatric population, including fractures, infection, and neoplasm.
The coracoid is a beak-like projection that extends anteriorly from the ventral scapula. It serves as the origin for the pectoralis minor, coracobrachialis, and short head of the biceps. Ligamentous attachments extend from the coracoid to the clavicle (coracoclavicular ligaments), acromion (coracoacromial ligament), and humerus (coracohumeral ligament). Additionally, the transverse scapular ligament attaches to the coracoid base.
The growth plate at the coracoid base is considered a “bipolar growth plate” and is made up of the primary ossification centers of the coracoid and the adjacent ventral scapula, similar to the tri-radiate cartilage of the acetabulum. The coracoid appears within the first year of life with fusion of the coracoid base growth plate occurring by age 14 to 15.
Physeal injuries occur at the base of the coracoid with imaging characteristics similar to other more typical locations (i.e. the proximal humerus in Little Leaguer’s shoulder). Key features include physeal widening with irregular bony margins, thought to be secondary to chronic repetitive pull from the attached musculature. Additionally, coracoid fractures occur in acute trauma and can be easily overlooked as they are frequently associated with other fractures. Direct blunt trauma by either an external object or the humeral head are associated with fractures of the base of the coracoid. Avulsions of the coracoid tip are seen with acromioclavicular separations with injury to the cocacoclavicular ligaments, more commonly seen in the pediatric population as the ligaments are relatively stronger than their osseous attachments.
While tumors of the coracoid are rare and more commonly occur in adults, primary tumors of the coracoid are seen in the pediatric population with case reports of osteoid osteomas, osteoblastomas, giant cell tumors, and aneurysmal bone cysts. Awareness of pathology affecting the coracoid process is helpful to the radiologist and clinician caring for the child with shoulder pain.
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Authors: Sharp Paige , Braithwaite Kiery , Marshall Kelley
Keywords: Physis, Fracture, Osteoid osteoma
Final Pr. ID: Poster #: SCI-026
To test radiographic diagnostic accuracy for distinguishing between stable distal radius buckle fractures (BF) from other distal radius fractures (DRF) after introducing a measurement guideline.
Background: Management of pediatric forearm fractures has become fracture specific, as treatment of the common stable BF is trending toward home management with a removable wrist splint while other potentially unstable, DRF require immobilization and orthopaedic follow-up. Diagnostic accuracy between BF and DRF is therefore imperative. We developed and suggested our radiologists use a measurement guideline to aid diagnosis with this general rule: an isolated distal radius fracture in a child > 7y is not likely to be a BF if the fracture-to-physis distance is < 1 cm.
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Authors: Ruess Lynne , Samora Julie
Keywords: Quality Improvement, fracture, radiography
Final Pr. ID: Paper #: 061
Radiologic diagnosis of rib fractures in suspected infant abuse is often challenging, and costochondral junction (CCJ) rib fractures can be particularly problematic. In an effort to enhance diagnostic accuracy and dating, we studied the dynamic radiologic spectrum of CCJ rib fractures on serial skeletal surveys (SSs). Read More
Authors: Tsai Andy , Kleinman Paul
Keywords: Abuse, Fractures, Radiography
Messer Diana, Adler Brent, Ruess Lynne, Brink Farah, Xiang Henry, Agnew Amanda
Final Pr. ID: Paper #: 055
Healing fractures are a common radiographic finding in cases of child physical abuse. Accurate time since injury estimation of healing fractures may provide an opportunity for identification and characterization of physical abuse, especially in young children unable to verbalize. This study examines patterns of long bone fracture healing in a modern sample of young children. Read More
Authors: Messer Diana , Adler Brent , Ruess Lynne , Brink Farah , Xiang Henry , Agnew Amanda
Keywords: Child Abuse, Fracture Healing, Radiography
Lucin Michael, Faruqui Sami, Sato Yutaka, Sato T Shawn
Final Pr. ID: Poster #: EDU-095
Because of the consequences of missed non-accidental trauma, it is essential for pediatric radiologists to have a high index of suspicion for injuries related to non-accidental trauma. Certain patterns of fracture raise suspicion for non-accidental trauma and are often considered pathognomonic. We present several cases of fractures that are typically considered pathognomonic for non-accidental trauma that had other non-abuse etiologies. These cases include classic metaphyseal lesions, subdural hematomas and long bone fracture in non-ambulatory patients among others. While there may be non-abuse etiologies of fractures that are classically considered pathognomonic for child abuse, the illustrative cases demonstrate the severe magnitude of injury necessary to produce these findings. This is why it is essential to evaluate the patient history and identify if the resulting injuries are consistent with the history. Read More
Authors: Lucin Michael , Faruqui Sami , Sato Yutaka , Sato T Shawn
Keywords: Non-accidental trauma, Fracture
Kuppler Kevin, Warnick Drew, Kucera Jennifer
Final Pr. ID: Poster #: EDU-025
The fishtail deformity of the distal humerus is a rare entity that most often develops as late sequela of a pediatric elbow fracture. The observed morphologic changes that define this diagnosis have been attributed to vascular compromise of the lateral trochlea and subsequent resorption or failure of development of the trochlear ossification center (dependent upon the skeletal maturity of the patient at time of initial injury). The purpose of this exhibit is to demonstrate the imaging features that will allow radiologists to confidently diagnose a fishtail deformity of the distal humerus and to understand the pathogenesis behind the morphologic appearance. We will also discuss prognosis and management, knowledge that will allow the radiologist to be of additional value in multidisciplinary discussions. Read More
Authors: Kuppler Kevin , Warnick Drew , Kucera Jennifer
Keywords: Elbow fracture, Trochlea
Gonzalez Juan, Malik Archana, Kazmi Faaiza, Urbine Jaqueline, Poletto Erica, Mallon Mea
Final Pr. ID: Poster #: EDU-021
Fractures in children and adolescents appear different on radiographs than fractures in adults. Pediatric fractures can be very subtle and difficult to detect if the radiologist is not actively looking for them, and a missed fracture can result in severe impairment in the future. The purpose of the presentation is to show the characteristic findings of frequently missed fractures in children. Read More
Authors: Gonzalez Juan , Malik Archana , Kazmi Faaiza , Urbine Jaqueline , Poletto Erica , Mallon Mea
Keywords: Pediatric, undiagnosed, Fracture
Horst Kelly, Kennedy Jillian, Zingula Shannon, Thomas Kristen, Larson Nicholas, Mcdonald Jennifer, Hull Nathan, Binkovitz Larry
Final Pr. ID: Poster #: SCI-010
We sought to quantify the sensitivity of plain film interpretation for rib fractures in patients < 3 years of age. Acute rib fractures can be challenging to detect on plain film imaging and can have serious implications if they are attributed to child abuse. We retrospectively reviewed plain films with known rib fractures to quantify “missed” and “occult” fractures. Read More
Authors: Horst Kelly , Kennedy Jillian , Zingula Shannon , Thomas Kristen , Larson Nicholas , Mcdonald Jennifer , Hull Nathan , Binkovitz Larry
Keywords: rib fracture, occult fracture, missed fracture
Final Pr. ID: Poster #: CR-008
A 13-year-old male presented to the emergency department with acute penile shaft swelling and pain after falling in the shower onto a partially erect penis. Initial ultrasound of the penis demonstrated a hypoechoic collection within the right ventrolateral midshaft, adjacent to an apparent focal discontinuity of the tunica albuginea. Additionally, a normal appearing urethra was identified. The patient was emergently brought to the operating room where a correlating tunica albuginea defect was not identified (via artificial erection with saline injection into the right corpora cavernosa), suggesting the absence of a penile fracture. Follow-up penile MRI revealed a urethral duplication, with injury to the ventral aspect of the dorsal urethra and an adjacent complex fluid collection. This represented a peri-urethral hematoma/urinoma. The ventral urethra was intact and unremarkable, accounting for the normal urethra visualized sonographically.
Urethral duplication is a rare congenital anomaly characterized by two urethras with variation in their location and courses. Type IIA 2 (Effman classification; seen in this patient) is the most complex form where there is proximal fusion of the two urethras prior to bladder insertion. Clinical manifestations vary but include penile deformation, urinary incontinence, and urinary tract infections. Traumatic urethral injury seen in patients with duplication is rare with no case reports found on literature review. Moreover, penile fracture mimics are not common as a clinical scenario and sonographic findings are relatively specific. The presented case demonstrates a rare scenario that may serve as a penile fracture mimic.
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Authors: Epps Caleb , Smith Benjamin
Keywords: Duplicated Urethra, Penile Fracture, Urethral Injury
Hamouda Ehab, Gupta Achint, Chidambaram Viswanath Anand, Lee Guo Rui
Final Pr. ID: Poster #: CR-015
Post-traumatic osseous cystic lesions are a rare complication in children. An etiology of intramedullary fat seepage thorough the damaged bone cortex and its entrapment within the subperiosteum has been proposed. These lesions run a benign course and usually resolve spontaneously. The presence of fatty marrow gives it a distinct appearance which aids in its diagnosis and differentiation from other bone lesions.
This case demonstrates a fat-fluid level within the subperiosteal cystic lesion in MRI and this is a typical feature of post-traumatic cystic lesion in a child. Recognition of this feature allows for a confident diagnosis, cutting down on unnecessary, potentially invasive investigations.
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Authors: Hamouda Ehab , Gupta Achint , Chidambaram Viswanath Anand , Lee Guo Rui
Keywords: Cyst, Fracture, Distal radius
Brennan Brian, Henry M Katherine, Altaffer Ana, Wood Joanne
Final Pr. ID: Paper #: 113
Prior research describing risk of physical abuse in children with rib fractures has included children whose rib fractures were incidentally identified in the context of an abuse evaluation. In our practice, the child in whom a rib fracture is the first presenting injury can be a diagnostic challenge, and less is known about this population. Our objectives were to determine the prevalence of 1) additional injuries concerning for abuse, 2) diagnosis of abuse and 3) a report to Child Protective Services (CPS) among children <60 months presenting with rib fractures or with rib fractures identified incidentally during evaluation of a chief complaint unrelated to abuse. Read More
Authors: Brennan Brian , Henry M Katherine , Altaffer Ana , Wood Joanne
Keywords: Child Abuse, Fracture, Rib Fracture
Fenlon Edward, Degnan Andrew, Maddocks Alexis, Chen Susie, Jaramillo Diego
Final Pr. ID: Poster #: EDU-062
Proximal humeral epiphyseal fracture-separation is a rare fracture pattern in infants often associated with birth-related or non-accidental trauma, representing a Salter-Harris type I or type II fracture. Lack of a proximal humeral epiphyseal ossification center in most newborns or only subtle displacement of a small epiphyseal ossification center in older infants, makes this injury difficult to diagnose on plain radiographs, potentially leading to delayed diagnosis or misdiagnosis. Ultrasound and MRI are therefore useful imaging modalities in indeterminate cases.
Clinical findings of infant proximal humeral epiphyseal fracture-separation such as shoulder swelling, tenderness, and decreased active motion, overlap with more common entities including clavicular fracture, brachial plexus injury and osteomyelitis. Radiographs are often the first diagnostic study ordered to evaluate these symptoms but are insensitive due to minimal ossification of the proximal humeral epiphysis. Radiographs may be normal or show subtle displacement of the epiphyseal ossification center, apparent joint space widening, small metaphyseal fracture fragments or displacement of the proximal humeral metaphysis in relation to the scapula. These findings can be misdiagnosed as shoulder dislocation or pseudosubluxation due to a joint effusion. Careful review of the medical record may elucidate a history of difficult delivery with shoulder dystocia or suspected shoulder trauma.
Ultrasound and MRI are useful in indeterminate cases due to their ability to resolve the cartilaginous physis and proximal humeral epiphysis, and to resolve their relationship to the humeral shaft and cartilaginous labrum. Ultrasound has higher anatomic resolution and offers the flexibility to quickly image the asymptomatic contralateral shoulder and image in planes that best show the relationship between the non-ossified epiphysis and the humeral shaft. Doppler ultrasound demonstrates epiphyseal perfusion without the need for contrast administration, and serial ultrasound imaging can be used to evaluate healing and remodeling. MRI is more useful in evaluating cases where osteomyelitis and/or septic arthritis are being considered, or in cases of an inconclusive history suspicious for non-accidental trauma to evaluate for additional osseous and soft tissue injuries.
Several examples of typical proximal humeral epiphyseal fracture-separations in infants will be presented and the relevant imaging findings discussed.
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Authors: Fenlon Edward , Degnan Andrew , Maddocks Alexis , Chen Susie , Jaramillo Diego
Gensel Anna, Karmazyn Boaz, Forbes-amrhein Monica
Final Pr. ID: Paper #: 115
This study aimed to elucidate the imaging appearance of costochondral junction (CCJ) fractures in young children, determine the association with nonaccidental trauma (NAT), and suggest a mechanism for injury. Read More
Authors: Gensel Anna , Karmazyn Boaz , Forbes-amrhein Monica
Keywords: Child Abuse, CCJ fracture, NAT
Nguyen Michael, Hong Shijie, Sze Alyssa, Chang Benjamin, Nguyen Jie
Final Pr. ID: Paper #: 064
Scaphoid fractures are well-recognized in adults where delayed diagnosis and treatment of displaced or rotated fragments can produce avascular necrosis and long-term morbidity. In children, scaphoid fractures are uncommon, particularly in the skeletally immature, with an estimated incidence of 11 per 100,000, and there is a relative paucity of published literature on its imaging characteristics and clinical prognosis. Therefore, the purpose of this study was to investigate imaging findings, fracture locations, and the clinical outcomes of scaphoid fractures in pre-teen children. Read More
Authors: Nguyen Michael , Hong Shijie , Sze Alyssa , Chang Benjamin , Nguyen Jie
Keywords: Scaphoid, Fracture
Messer Diana, Adler Brent H., Brink Farah, Xiang Henry, Agnew Amanda
Final Pr. ID: Poster #: SCI-038
Skeletal fractures may go undetected and untreated in physically abused children for significant periods of time. When discovered later through radiographic survey, the time since injury (TSI) may be important for the medical diagnosis of physical abuse and have implications for child protection. Prior research suggests that clinical and biological variables, such as fracture location and age, may influence pediatric fracture healing. However, radiographic determination of TSI has been poorly studied until recently. It has been commonly understood that in general younger patients heal faster and lower extremity fractures heal slower than upper extremity fractures. However, the influence of patient age and fracture location on fracture healing has only been explored on a limited scale and not between pediatric age groups. This study examines the effect of age on specific features of pediatric fracture healing through radiographic analysis. Read More
Authors: Messer Diana , Adler Brent H. , Brink Farah , Xiang Henry , Agnew Amanda
Final Pr. ID: Poster #: EDU-027
Trampoline-related injuries in children are a common cause for presentation to the Emergency Department, and their incidence is increasing. Injuries to the lower limb are the most common. Transverse fractures of the proximal tibial metaphysis are a well-described classic fracture. These fractures may be subtle, only diagnosed at the time of follow up x rays. When reviewed at Radiology Quality Assurance meetings, these missed fractures were perceptible on the original imaging. We sought to examine the characteristics of fractures that were missed, and elucidate measures that could improve diagnostic accuracy. Read More
Authors: Mceniery Jane
Keywords: Trauma, Trampoline, Fracture, Quality Assurance, Emergency
Murray Nicolas, Rypens Françoise, Trudel Jean-sébastien, Cantin Marie-andrée, Miron Marie-claude
Final Pr. ID: Poster #: CR-069
Traumatic lesions to the sternum are uncommon, especially in the pediatric population. Sternal fractures require significant force to occur due to the greater thorax elasticity in children compared to adults. Sternal segment dislocation is extremely rare with only 13 cases reported in the literature. We report a case of traumatic sternal segment dislocation in a 3-year-old girl.
After falling on a pole, a 3-year-old girl presented chest pain increased by Valsalva and low-grade fever for few days. Her parents brought her to the hospital when she experienced a painful thoracic crisis with the development of a presternal lump. Ultrasonography showed an acoustic shadowing calcified mass representing the first sternal segment being dislocated and rotated at almost 90 degrees. CT showed dislocation with horizontal alignment of the first sternal segment and an undisplaced fracture line in the middle of this segment. There was soft tissue swelling but no repercussion on mediastinal structures. A bone scintigraphy was ordered to exclude any infectious process surimposed and was normal. Conservative management was elected. X-rays 2 months later showed partial remodeling of the sternum. Ten months after the initial trauma, patient remained asymptomatic. CT showed partial osteolysis of the first sternal segment compatible with osteonecrosis.
The main cause of sternal dislocation is direct trauma to chest wall. The sternal body is composed of 4 segments which begin to ossify early in childhood. The manubrium is rigidly attached to both the first ribs and clavicles, providing relative elasticity of other sternal segments. The first sternal segment is the most common dislocated segment. Patient usually presents with limited chest pain and anterior chest wall deformation. The diagnosis of sternal segment dislocation is based on history and physical exam. Imaging studies are useful to confirm the diagnosis. The sternal segment may be minimally dislocated initially, but can continue its rotation for about 2 weeks. Fragment gain stability at 90 degrees rotation. According to the review of the 13 published cases, both operative and conservative treatments show similar outcome.
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Authors: Murray Nicolas , Rypens Françoise , Trudel Jean-sébastien , Cantin Marie-andrée , Miron Marie-claude
Keywords: Pediatric, Sternal segment dislocation, Sernal fracture
Adeyiga Adebunmi, Bandarkar Anjum
Final Pr. ID: Poster #: EDU-135
Purpose:
1. Review focused elbow ultrasound technique for pediatric patients
2. Review normal pediatric elbow anatomy by ultrasound
3. Present a spectrum of pediatric elbow disorders evaluated by ultrasound and demonstrate correlative findings on radiography, arthrography and MRI.
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Authors: Adeyiga Adebunmi , Bandarkar Anjum
Keywords: Elbow Ultrasound, Congenital dislocation, transphyseal fracture, synovitis, hemophiliac arthropathy
Wyers Mary, Ganesh Ashwin, Samet Jonathan
Final Pr. ID: Poster #: EDU-037
Background & Purpose:
Fractures on MRI can be difficult to see, particularly if they are small or surrounded by edema and other heterogeneous signal changes. This is made more challenging if an x-ray is not available for review when reading an MRI, or if the injury on x-ray is subtle. The purpose of this exhibit is to review the different appearances and types of fractures by MRI, including avulsion, acute osteochondral, physeal related, and stress fractures, and help the learner develop a pattern-based approach when reviewing an MRI, in order to improve detection and confidence.
Learning Objectives:
1. Recognize the different ways an acute fracture can appear by MRI, including understanding mechanisms of injury and any associated ligamentous or tendinous involvement.
2. Learn to approach each MRI the same way, with a careful assessment of bone marrow edema heterogeneity, joint fluid heterogeneity, and articular surfaces.
3. Develop awareness of subtle, small, or unusual fractures that may be hiding amidst edema or fluid.
Content:
This exhibit will portray and explain the imaging appearances of different fractures on MRI including: incomplete, avulsion, acute osteochondral, physeal related, and stress fractures. Different joint centered abnormalities will be emphasized, particularly the knee, shoulder, and pelvis. A pattern based approach will be reviewed in order to avoid missing subtle findings. This will include:
1. Searching within the heterogeneity of marrow edema patterns on both T1 and T2 weighted sequences to find linearity, subtle cortical depressions, or incomplete fracture lines.
2. Looking for healing or more chronic changes, including periosteal reaction by MRI.
3. Following articular cartilage and the physis to make sure they have normal contours and are smooth.
4. Examining joint fluid for avulsed joint bodies, with attention to any linear appearing signal changes in the dependent recesses of joints.
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Authors: Wyers Mary , Ganesh Ashwin , Samet Jonathan