Imaging of pediatric musculoskeletal trauma: Age-specific considerations and challenges

Table 3 Advanced imaging modalities

Type1	Category	Subcategory and examples	Imaging modality indications
Acute trauma	Fractures	Physeal fractures: SH Type I-V; special adolescent variants: Tillaux (SH-III); Triplane (SH-IV). Incomplete fractures: Greenstick; torus/buckle; “Bowing”. Complete fractures: Transverse; comminuted; oblique. NAT fractures: Metaphyseal fractures; rib fractures; sternal fractures	Radiographs: Gold standard for initial evaluation. Advanced imaging: CT: For complex intra-articular or surgical planning MRI: Not for routine fracture detection; best for associated soft tissue, cartilage, or growth plate injury. Suspected NAT (based on RCH guidelines) < 2 years old: Primary: Full skeletal survey (mandatory). Follow-up: Limited skeletal survey after 14 days and no later than 28 days, to detect healing fractures. 2-5 years old: Assessment: Case-by-case depending on history, clinical signs and suspicion. Options: Skeletal survey; bone scan if expertise available. > 5 years old: Approach: Targeted imaging guided by clinical findings. Modalities: Radiographs o symptomatic areas; advanced imaging (CT/MRI) for specific injuries. Advanced imaging modalities: Bone scan: Only with appropriate expertise and when SS is limited/inconclusive. CT: Head CT for suspected abusive head trauma; CT chest/abdomen/pelvis only if unstable or visceral injury suspected. MRI: Brain/spine MRI for parenchymal, ischemic, ligamentous, or occult injury notes: US: May support abdominal or intracranial assessment but it’s not primary for skeletal injuries
	Soft tissue injuries. Note: These are less common than fractures as the bone is the weakest component in children	Ligaments: Sprains/partial tears; complete tears. Muscle-tendon unit: Apophyseal avulsions: Tendon ruptures (rarer). Cartilage. Osteochondral lesions	US: First-line for superficial injuries, effusions, apophyseal avulsions. MRI: Preferred for deep, complex, or preoperative assessment. CT: Only for polytrauma or when MRI unavailable
Chronic/overuse trauma		Overuse injuries: Stress fractures; Gymnast’s wrist. Little league shoulder; Little league elbow (medial epicondyle apophysitis). Sever’s disease (calcaneal apophysitis). Osgood Schlatter: Sinding larsen johanson	Radiographs: First-line in most cases due to accessibility and ability to detect physeal changes, fragmentation, and obvious stress reactions. MRI: Most useful modality for many overuse injuries in children. It detects early stress reactions, marrow edema, cartilage/physeal injury, and osteochondral involvement, without radiation exposure. CT: Largely supplanted by MRI in pediatrics due to radiation concerns. Still occasionally useful for surgical planning or equivocal cases. US: Limited but sometimes useful for superficial apophyseal or tendon-related pathology (e.g. Osgood-Schlatter, sever disease), especially when radiation avoidance is a priority. Note: CT is rarely needed; MRI avoids radiation and provides superior tissue contrast

¹Acute: Single, identifiable event; chronic/overuse: Repetitive trauma.

SH: Salter Harris; NAT: Non-accidental trauma; CT: Computed tomography; MRI: Magnetic resonance imaging; US: Ultrasound; SS: Skeletal survey; RHC: Royal children’s hospital.