Ku Alexei,  Schmitz Kelli

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. Read More

Authors:  Ku Alexei , Schmitz Kelli

Keywords:  physis, fracture, athlete

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

Boyd Kevin,  Thakrar Pooja

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

Malavia Mira,  Rivard Douglas

Final Pr. ID: Poster #: EDU-068

Ischial tuberosity avulsion fractures, though not uncommon in adolescent athletes, are often overlooked or misdiagnosed. These fractures occur more frequently in males than females. Primary cause of this fracture type is usually a sudden eccentric load on the proximal hamstrings, typically seen during a kicking action in dance, football, or soccer. Due to the limited use of imaging in the evaluation of such injuries, these fractures often are misdiagnosed or underdiagnosed. Recent injuries warrant more conservative management, including rest and relative immobilization. In cases of late diagnosis, delayed healing, or persistent symptomatology, surgical intervention can be undertaken to restore normal anatomy, alleviate symptoms, and facilitate healing. Minimally invasive CT-guided percutaneous needle fenestration has been introduced for symptomatic delayed union ischial tuberosity fractures in adolescents. This percutaneous procedure involves the creation of multiple channels into the bone at the fracture site with an 18 gauge Chiba needle via image guided needle fenestration to enhance blood flow and promote healing of the target area. Following this, a tailored physical therapy program is implemented based on patient symptomatology, individual tissue healing rates, and the current literature related to proximal hamstring injuries. Outcomes to this minimally invasive approach have been promising including cases of complete pain relief, full functional recovery, and a return to sports without limitations.

Outline of Teaching Points:
Ischial tuberosity avulsion fractures are common in adolescent athletes, with a higher incidence in males, caused by sudden eccentric loads on proximal hamstrings during activities like dance, football, or soccer.
Due to limited imaging use, these fractures are often overlooked or misdiagnosed, leading to delayed healing or persistent symptoms.
Recent injuries may benefit from conservative management, involving rest and relative immobilization.
Surgical intervention becomes necessary for late diagnoses, delayed healing, or persistent symptoms to restore normal anatomy and alleviate symptoms.
Minimally invasive CT-guided percutaneous needle fenestration has shown promising outcomes, facilitating healing with complete pain relief and a return to sports without limitations. Read More

Authors:  Malavia Mira , Rivard Douglas

Keywords:  fracture, interventional radiology

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. Read More

Authors:  Sharp Paige , Braithwaite Kiery , Marshall Kelley

Keywords:  Physis, Fracture, Osteoid osteoma

Kosaraju Sriya,  Errampalli Eric,  Illimoottil Mathew,  Illimoottil Sarah,  Tran Noelle,  Leland Kristin,  Mardis Neil

Final Pr. ID: Poster #: EDU-061

The diagnosis of non accidental trauma (NAT) has significant clinical, therapeutic and social implications for the patient and the family. The recognition of suspicious fractures and fracture patterns, in conjunction with the clinical findings, plays an important role in the accurate diagnosis. However, there are congenital, metabolic and infectious processes that can mimic skeletal findings of NAT. Radiologists must be cognizant of these mimics and recognize the imaging and clinical findings that differentiate them from NAT to ensure accurate diagnosis and appropriate intervention.

This educational exhibit aims to elucidate the key radiographic features and clinical presentations that distinguish NAT from conditions that can mimic its appearance, such as osteogenesis imperfecta, rickets, and metabolic bone diseases.

Through a series of case studies and imaging examples, we will explore the skeletal findings of NAT mimics and compare them with the common fracture patterns associated with NAT, highlighting the imaging and clinical findings that differentiate the two. We will emphasize the importance of a thorough patient history and multidisciplinary approach in evaluating suspected cases of abuse.

By understanding the nuances of NAT mimics, radiologists can improve their diagnostic acumen, reduce the risk of misdiagnosis, and ultimately contribute to better patient outcomes. Read More

Authors:  Kosaraju Sriya , Errampalli Eric , Illimoottil Mathew , Illimoottil Sarah , Tran Noelle , Leland Kristin , Mardis Neil

Keywords:  Fractures, Skeletal Survey, NAT/Abuse

Ruess Lynne,  Samora Julie

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. Read More

Authors:  Ruess Lynne , Samora Julie

Keywords:  Quality Improvement, fracture, radiography

Tsai Andy,  Kleinman Paul

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

Schultz Rebecca,  Henkel Erin,  Smith Brian,  Kan J.,  Amaral Jason,  Bridges Callie,  Gladstein Aharon,  Wall Jon,  Bih Eric,  Kraus Steven,  Cruz Andrea,  Allen Joseph

Final Pr. ID: Poster #: SCI-020

Our institution employs the modified Gartland classification system for operative and non-operative supracondylar humeral fracture (SCHF) communication. The purpose of our study is to assess the inter-observer reliability of the Gartland classification between pediatric radiologists, orthopedic surgeons, and pediatric emergency physicians. Read More

Authors:  Schultz Rebecca , Henkel Erin , Smith Brian , Kan J. , Amaral Jason , Bridges Callie , Gladstein Aharon , Wall Jon , Bih Eric , Kraus Steven , Cruz Andrea , Allen Joseph

Keywords:  supracondylar humerus fracture, interobserver reliability

Illimoottil Mathew,  Errampalli Eric,  Kosaraju Sriya,  Priya Lakshmi,  Orscheln Emily

Final Pr. ID: Poster #: EDU-054

Ankle fractures in the pediatric population pose unique diagnostic and therapeutic challenges due to the evolving anatomy of the child. However, when knowledge of this anatomic evolution intersects with knowledge of injury mechanisms that are often at play, the radiologist can understand that pediatric ankle fractures often occur in predictable patterns. This educational exhibit explores the various classifications of pediatric ankle injuries, encompassing Dias-Tachdjian, Salter Harris, and transitional fractures. Recognizing the significant anatomical and developmental differences between skeletally immature and mature ankles, we investigate the dissimilarities in fracture patterns that emerge in these two populations. Our exhibit explores the influence of the physis, ossification centers, supporting soft tissue structures, and differing anatomical proportions on fracture patterns in these populations, providing pediatric radiologists with valuable insights into the interpretation of pediatric ankle fractures. This comprehensive overview ensures a well-rounded understanding of the unique injury patterns and facilitates improved decision-making for treatment. Read More

Authors:  Illimoottil Mathew , Errampalli Eric , Kosaraju Sriya , Priya Lakshmi , Orscheln Emily

Keywords:  ankle, fracture

Karam Izabel,  Yamachira Viviane,  Silva Camila,  De Paula Vitor,  Urbanetz Almir Antonio,  Gual Fabiana,  Takahashi Marcelo,  Santos Durval,  Rosemberg Laercio Alberto,  Sameshima Yoshino,  Francelino Rebeca,  Kuhn Gabriel,  Moura Fe Taila,  Yoshimura Fabio,  Castro Adham,  Baptista Eduardo,  Grando Paulo Eduardo,  Nagaya Erina

Final Pr. ID: Poster #: EDU-072

The purposes of this exhibit are:
- review the peculiarities of the immature skeleton;
- illustrate the bone fractures that are exclusively found in children;
- alert to the imaging findings that should raise the suspicion to non-accidental traumas. Read More

Authors:  Karam Izabel , Yamachira Viviane , Silva Camila , De Paula Vitor , Urbanetz Almir Antonio , Gual Fabiana , Takahashi Marcelo , Santos Durval , Rosemberg Laercio Alberto , Sameshima Yoshino , Francelino Rebeca , Kuhn Gabriel , Moura Fe Taila , Yoshimura Fabio , Castro Adham , Baptista Eduardo , Grando Paulo Eduardo , Nagaya Erina

Keywords:  Fractures

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

Steinhardt Nicole,  Marine Megan,  Supakol Nucharin,  Radhakrishnan Rupa,  Lahiri Niloy,  Jennings Greg,  Thompson Shannon,  Karmazyn Boaz

Final Pr. ID: Poster #: SCI-023

The purpose of this poster is to review the imaging findings of spinal fractures in children evaluated for child abuse on radiography, CT, and MRI, and differentiate fractures from vertebral body variations. Read More

Authors:  Steinhardt Nicole , Marine Megan , Supakol Nucharin , Radhakrishnan Rupa , Lahiri Niloy , Jennings Greg , Thompson Shannon , Karmazyn Boaz

Keywords:  Child abuse, spinal fractures, Vertebral variations

Kosaraju Sriya,  Errampalli Eric,  Illimoottil Mathew,  Priya Lakshmi,  Orscheln Emily

Final Pr. ID: Poster #: EDU-071

Fractures are a common occurrence in pediatric patients with around one third of children sustaining at least one by the age of 17 years. As the pediatric osseous structures develop, secondary ossification centers will become radiographically evident and there may be several of these ossification centers in single bone. As a child approaches skeletal maturity, the physis will gradually close and the primary and secondary ossification centers fuse. These processes often occur in known and predictable patterns. However, there are numerous cartilaginous physes and secondary ossification center variants that can potentially create a diagnostic dilemma for the radiologist. Knowledge of location and expected time of secondary ossification center appearance and physeal fusion in the pediatric patient is vital to distinguish them from fractures in a trauma setting. Accurate diagnosis of fractures is necessary for facilitation of appropriate management and prevention of subsequent deformity in the growing skeleton. Upper extremity fractures are encountered significantly more frequently than lower extremity fractures in pediatrics. However, there are a number of normal structures that may serve as fracture mimics in the upper extremity, particularly at the shoulder and elbow. In this educational exhibit, we aim to describe the expected changes in visible ossification centers and physes in the osseous structures of the shoulder and elbow, highlight some common and
uncommon variations in the expected sequence, and highlight potential pitfalls related to this variation that may be mistaken for fracture or may result in an unrecognized fracture. Read More

Authors:  Kosaraju Sriya , Errampalli Eric , Illimoottil Mathew , Priya Lakshmi , Orscheln Emily

Keywords:  elbow, shoulder, fracture

Epps Caleb,  Smith Benjamin

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. Read More

Authors:  Epps Caleb , Smith Benjamin

Keywords:  Duplicated Urethra, Penile Fracture, Urethral Injury

Jones Chad,  Woodward Connor,  Woo Raymund,  Williams Jennifer

Final Pr. ID: Poster #: EDU-051

The overall incidence of birth trauma ranges from 2-3%, with the large majority consisting of superficial soft tissue injury. Musculoskeletal birth trauma tends to occur most commonly around the shoulder, with clavicle and brachial plexus injuries representing the majority of MSK trauma. Perinatal long bone fractures are quite rare, with most affecting the humeral/femoral diaphysis. Physeal fractures represent an even more uncommon entity and can be radiographically occult due to non-ossification of the epiphysis in neonates. In our educational poster, we present a variety of perinatal fractures of the physis which were initially occult on radiograph, but became evident on further workup with MR. Read More

Authors:  Jones Chad , Woodward Connor , Woo Raymund , Williams Jennifer

Keywords:  Fracture, Physis, Perinatal

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.

Read More

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. Read More

Authors:  Fenlon Edward , Degnan Andrew , Maddocks Alexis , Chen Susie , Jaramillo Diego

Keywords:  Fracture, Infant, Trauma

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

Keywords:  Fracture, Healing, Abuse

Mceniery Jane

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. Read More

Authors:  Murray Nicolas , Rypens Françoise , Trudel Jean-sébastien , Cantin Marie-andrée , Miron Marie-claude

Keywords:  Pediatric, Sternal segment dislocation, Sernal fracture