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

Table 4 Non-accidental trauma vs accidental trauma

	Non-accidental trauma	Accidental trauma
Definition	Intentional physical harm inflicted by a caregiver (child abuse)	Unintentional injury (e.g. fall, sports, motor vehicle accident)
History/context	Inconsistent or changing history; delay in seeking care; injuries incompatible with child’s developmental stage (e.g., long bone fracture in a non-ambulatory infant)	Clear, consistent explanation of mechanism; injury matches developmental ability and timeline of presentation
Clinical clues	Bruises in atypical areas (torso, ears, neck-TEN rule; FACESp: Frenulum, angle of jaw, cheeks, eyelids, subconjunctiva); patterned bruises or burns; oral/sentinel injuries	Bruises over bony prominences (forehead, shins); abrasions/lacerations consistent with play or falls
Injury distribution	Multiple fractures at different healing stages; bilateral or symmetric injuries; high-specificity sites: Posterior ribs, classic metaphyseal lesions, scapula, sternum, pelvis	Usually single, isolated fracture; pattern matches mechanism (e.g., supracondylar humerus from FOOSH, toddler’s tibial spiral fracture, clavicle or buckle fracture)
First line imaging	Skeletal survey (< 2 years): Full series to detect acute, occult, and healing fractures; repeat limited survey at about 2 weeks increases sensitivity	Radiographs targeted to site of injury; sufficient in most cases
Other imaging	CT: Head CT for suspected abusive head trauma; chest/abdomen/pelvis CT only if unstable or high suspicion of internal injury. MRI: Brain MRI for parenchymal injury, ischemia, dating hemorrhage; spine MRI for occult fractures/Ligamentous injury in AHT; MSK MRI for complex/occult injuries	CT: Used when radiographs are insufficient or in severe head injury/neurological deficit. MRI: For selected complex fractures or suspected ligament/cartilage injury
Head trauma: Neuroimaging findings	Abusive head trauma: Subdural hemorrhage (often multiple or of varying ages), hypoxic-ischemic injury, spinal spinal subdural hemorrhage, retinal hemorrhages (clinical exam)	Isolated linear skull fractures, epidural hematoma with clear trauma history
Differential diagnoses	Bone fragility disorders (osteogenesis imperfecta, rickets, metabolic bone disease of prematurity, copper deficiency/Menkes, scurvy) can mimic fracture patterns; careful correlation with clinical and lab findings required	Consider NAT when the patterns/distributions are inconsistent (e.g. more than 3 bruises from a single event or bruises over opposite sides of the body). Note that accidental patterns rarely overlap with high-specificity injuries seen in NATs

TEN: Torso-ears–neck bruising rule; FACESp: Frenulum, angle of jaw, cheeks, eyelids, subconjunctiva; FOOSH: Fall on outstretched hand; CT: Computed tomography; MRI: Magnetic resonance imaging; MSK: Musculoskeletal; NAT: Non-accidental trauma; AHT: Abusive head trauma.