Validating scoring systems for fracture healing in infants and young children: pilot study

Abstract

Background Recent studies have analysed birth-related clavicular fractures to propose time frames for healing that could be applied to dating of all fractures in cases of suspected child abuse. Objective To assess differences in healing rates between femoral fractures and birth-related clavicular fractures in infants and young children. Materials and methods A retrospective 5-year pilot study of femoral fractures in children younger than 3 years of age was performed. Anonymised radiographs were independently scored by two radiologists for stages of fracture healing. In cases of reader disagreement, radiographs were independently scored by a third radiologist. Results In total, 74 radiographs (30 children) met the inclusion criteria. Fracture healing evolved over time with subperiosteal new bone formation (SPNBF) appearing first, followed by callus then remodelling. A power calculation for a single proportion, with a level of confidence of 95% and a margin of error of 5%, showed that in a definitive study, 359 radiographs would be required. Conclusion Although the overall pattern of healing is similar, in this small pilot study, the earliest times for SPNBF and callus formation in femoral fractures appeared to lag behind healing of birth-related clavicular fractures. Remodelling appeared earlier than remodelling of clavicular fractures. A power calculation has determined numbers of femoral radiographs (359) required for a definitive study.

Controversial aspects of imaging in child abuse: a second roundtable discussion from the ESPR child abuse taskforce

“…The 4 more recent published studies [20][21][22][23] support some of the findings from the earlier published literature: a predictable pattern of radiological fracture healing for both long bone and clavicular fractures; good concordance regarding the first appearance of SPNBF, this usually being present by 11 days (range 7 to 12 days); and good concordance for bony remodelling, this being present by 42 days (range 26 to 51 days) in all studies where it was assessed. There was no consistency between studies when considering callus formation (first or mature) or the bridging phases of bone healing.…”

“…Yet, several published timetables for fracture healing included older children and adolescents in their analyses [ 15 , 16 , 19 ]. There are 7 studies which concentrated on fracture healing in children aged less than 5 years [ 14 , 18 , 20 – 23 , 26 ]. Of these, only 4 assessed fracture healing in children under the age of 3 years of age [ 20 – 23 ].…”

“…There are 7 studies which concentrated on fracture healing in children aged less than 5 years [ 14 , 18 , 20 – 23 , 26 ]. Of these, only 4 assessed fracture healing in children under the age of 3 years of age [ 20 – 23 ].…”

“…In addition, the range of patient ages, the location of the fractures and whether the injuries were accidental or inflicted were not reported. The published literature on fracture dating is otherwise limited to a few small studies and texts, most of which include suggested timetables for the phases of fracture healing (Table 1) [13][14][15][16][17][18][19][20][21][22][23]. Whilst there are some similarities between some of the suggested timetables, there are also significant differences which, from a practical and legal perspective, question their accuracy and validity in assisting fracture dating.…”

“…Yet, several published timetables for fracture healing included older children and adolescents in their analyses [15,16,19]. There are 7 studies which concentrated on fracture healing in children aged less than 5 years [14,18,[20][21][22][23]26] [16]. Both studies excluded children under the age 12 months from their analyses-the group most at risk for abusive fractures.…”