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Pediatrics
Diagnosis
Musculoskeletal
Trauma: General
Fracture Complications
Fracture Complications
Arthur B. Meyers, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Clinical Issues

        • Diagnostic Checklist

          TERMINOLOGY

          • Complications Encountered

            • Nonunion: Lack of bony union > 6 months after injury with corresponding clinical signs/symptoms
            • Delayed union: Lack of union by 6 months but with imaging &/or clinical signs of healing; eventually heals
            • Malunion: Healing with nonanatomic alignment of fracture fragments
            • Premature physeal closure/growth arrest: Osseous physeal bridge (bar) forms across otherwise unfused cartilaginous physis
              • May lead to angular deformity or limb length discrepancy
            • Osteonecrosis: Disruption of blood supply to fracture fragment with resulting infarction
            • Chondrolysis: Progressive destruction of articular cartilage; may lead to premature degenerative arthritis
            • Posttraumatic lipid inclusion cyst: Subperiosteal focus of marrow fat entrapped in remodeled cortex (due to transposition of fatty marrow during prior fracture)
            • Others: Infection, degenerative changes, refracture

          IMAGING

          • General Features

            CLINICAL ISSUES

            • Nonunion

              • Malunion

                • Premature Physeal Closure

                  • Posttraumatic Lipid Inclusion Cysts

                    • Degenerative Change

                      • Osteonecrosis

                        DIAGNOSTIC CHECKLIST

                        • Reporting Tips

                          Selected References

                          1. Kim HHR et al: Uniquely pediatric upper extremity injuries. Clin Imaging. 80:249-61, 2021
                          2. Meyers AB: Physeal bridges: causes, diagnosis, characterization and post-treatment imaging. Pediatr Radiol. 49(12):1595-609, 2019
                          3. Pianta M et al: Dual-energy contrast-enhanced CT to evaluate scaphoid osteonecrosis with surgical correlation. J Med Imaging Radiat Oncol. 63(1):69-75, 2019
                          4. Nguyen JC et al: Imaging of pediatric growth plate disturbances. Radiographics. 37(6):1791-812, 2017
                          5. Fox MG et al: Accuracy of enhanced and unenhanced MRI in diagnosing scaphoid proximal pole avascular necrosis and predicting surgical outcome. Skeletal Radiol. 44(11):1671-8, 2015
                          6. Larribe M et al: Usefulness of dynamic contrast-enhanced MRI in the evaluation of the viability of acute scaphoid fracture. Skeletal Radiol. 43(12):1697-703, 2014
                          7. Glotzbecker MP et al: Fishtail deformity of the distal humerus: a report of 15 cases. J Pediatr Orthop. 33(6):592-7, 2013
                          8. Schmitt R et al: Avascular necrosis (AVN) of the proximal fragment in scaphoid nonunion: is intravenous contrast agent necessary in MRI? Eur J Radiol. 77(2):222-7, 2011
                          9. Fox MG et al: Assessment of scaphoid viability with MRI: a reassessment of findings on unenhanced MR images. AJR Am J Roentgenol. 195(4):W281-6, 2010
                          10. Kang HG et al: Resection of a physeal bar under computer-assisted guidance. J Bone Joint Surg Br. 92(10):1452-5, 2010
                          11. Silva M et al: Inter- and intra-observer reliability of the Baumann angle of the humerus in children with supracondylar humeral fractures. Int Orthop. 34(4):553-7, 2010
                          12. Anz AW et al: Pediatric scaphoid fractures. J Am Acad Orthop Surg. 17(2):77-87, 2009
                          13. Shrader MW et al: Nonunion of fractures in pediatric patients: 15-year experience at a level I trauma center. Orthopedics. 32(6):410, 2009
                          14. Brubacher JW et al: Pediatric supracondylar fractures of the distal humerus. Curr Rev Musculoskelet Med. 1(3-4):190-6, 2008
                          15. Nagy L et al: Correction of forearm malunion guided by the preoperative complaint. Clin Orthop Relat Res. 466(6):1419-28, 2008
                          16. Omid R et al: Supracondylar humeral fractures in children. J Bone Joint Surg Am. 90(5):1121-32, 2008
                          17. Bushnell BD et al: Malunion of the distal radius. J Am Acad Orthop Surg. 15(1):27-40, 2007
                          18. Huckstadt T et al: Pediatric fractures of the carpal scaphoid: a retrospective clinical and radiological study. J Pediatr Orthop. 27(4):447-50, 2007
                          19. Price CT et al: Osteotomy for malunited forearm shaft fractures in children. J Pediatr Orthop. 26(2):193-6, 2006
                          20. Anderson SE et al: MR imaging of avascular scaphoid nonunion before and after vascularized bone grafting. Skeletal Radiol. 34(6):314-20, 2005
                          21. Gicquel P et al: Problems of operative and non-operative treatment and healing in tibial fractures. Injury. 36 Suppl 1:A44-50, 2005
                          22. Khoshhal KI et al: Physeal bridge resection. J Am Acad Orthop Surg. 13(1):47-58, 2005
                          23. Papadimitriou NG et al: Post-traumatic cystic lesion following fracture of the radius. Skeletal Radiol. 34(7):411-4, 2005
                          24. Ecklund K et al: Patterns of premature physeal arrest: MR imaging of 111 children. AJR Am J Roentgenol. 178(4):967-72, 2002
                          25. Waters PM et al: Surgical management of posttraumatic distal radial growth arrest in adolescents. J Pediatr Orthop. 22(6):717-24, 2002
                          26. Ecklund K et al: Imaging of growth disturbance in children. Radiol Clin North Am. 39(4):823-41, 2001
                          27. Goldfarb CA et al: Wrist fractures: what the clinician wants to know. Radiology. 219(1):11-28, 2001
                          28. Cerezal L et al: Usefulness of gadolinium-enhanced MR imaging in the evaluation of the vascularity of scaphoid nonunions. AJR Am J Roentgenol. 174(1):141-9, 2000
                          Related Anatomy
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                          Related Differential Diagnoses
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                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Terminology

                            • Imaging

                              • Clinical Issues

                                • Diagnostic Checklist

                                  TERMINOLOGY

                                  • Complications Encountered

                                    • Nonunion: Lack of bony union > 6 months after injury with corresponding clinical signs/symptoms
                                    • Delayed union: Lack of union by 6 months but with imaging &/or clinical signs of healing; eventually heals
                                    • Malunion: Healing with nonanatomic alignment of fracture fragments
                                    • Premature physeal closure/growth arrest: Osseous physeal bridge (bar) forms across otherwise unfused cartilaginous physis
                                      • May lead to angular deformity or limb length discrepancy
                                    • Osteonecrosis: Disruption of blood supply to fracture fragment with resulting infarction
                                    • Chondrolysis: Progressive destruction of articular cartilage; may lead to premature degenerative arthritis
                                    • Posttraumatic lipid inclusion cyst: Subperiosteal focus of marrow fat entrapped in remodeled cortex (due to transposition of fatty marrow during prior fracture)
                                    • Others: Infection, degenerative changes, refracture

                                  IMAGING

                                  • General Features

                                    CLINICAL ISSUES

                                    • Nonunion

                                      • Malunion

                                        • Premature Physeal Closure

                                          • Posttraumatic Lipid Inclusion Cysts

                                            • Degenerative Change

                                              • Osteonecrosis

                                                DIAGNOSTIC CHECKLIST

                                                • Reporting Tips

                                                  Selected References

                                                  1. Kim HHR et al: Uniquely pediatric upper extremity injuries. Clin Imaging. 80:249-61, 2021
                                                  2. Meyers AB: Physeal bridges: causes, diagnosis, characterization and post-treatment imaging. Pediatr Radiol. 49(12):1595-609, 2019
                                                  3. Pianta M et al: Dual-energy contrast-enhanced CT to evaluate scaphoid osteonecrosis with surgical correlation. J Med Imaging Radiat Oncol. 63(1):69-75, 2019
                                                  4. Nguyen JC et al: Imaging of pediatric growth plate disturbances. Radiographics. 37(6):1791-812, 2017
                                                  5. Fox MG et al: Accuracy of enhanced and unenhanced MRI in diagnosing scaphoid proximal pole avascular necrosis and predicting surgical outcome. Skeletal Radiol. 44(11):1671-8, 2015
                                                  6. Larribe M et al: Usefulness of dynamic contrast-enhanced MRI in the evaluation of the viability of acute scaphoid fracture. Skeletal Radiol. 43(12):1697-703, 2014
                                                  7. Glotzbecker MP et al: Fishtail deformity of the distal humerus: a report of 15 cases. J Pediatr Orthop. 33(6):592-7, 2013
                                                  8. Schmitt R et al: Avascular necrosis (AVN) of the proximal fragment in scaphoid nonunion: is intravenous contrast agent necessary in MRI? Eur J Radiol. 77(2):222-7, 2011
                                                  9. Fox MG et al: Assessment of scaphoid viability with MRI: a reassessment of findings on unenhanced MR images. AJR Am J Roentgenol. 195(4):W281-6, 2010
                                                  10. Kang HG et al: Resection of a physeal bar under computer-assisted guidance. J Bone Joint Surg Br. 92(10):1452-5, 2010
                                                  11. Silva M et al: Inter- and intra-observer reliability of the Baumann angle of the humerus in children with supracondylar humeral fractures. Int Orthop. 34(4):553-7, 2010
                                                  12. Anz AW et al: Pediatric scaphoid fractures. J Am Acad Orthop Surg. 17(2):77-87, 2009
                                                  13. Shrader MW et al: Nonunion of fractures in pediatric patients: 15-year experience at a level I trauma center. Orthopedics. 32(6):410, 2009
                                                  14. Brubacher JW et al: Pediatric supracondylar fractures of the distal humerus. Curr Rev Musculoskelet Med. 1(3-4):190-6, 2008
                                                  15. Nagy L et al: Correction of forearm malunion guided by the preoperative complaint. Clin Orthop Relat Res. 466(6):1419-28, 2008
                                                  16. Omid R et al: Supracondylar humeral fractures in children. J Bone Joint Surg Am. 90(5):1121-32, 2008
                                                  17. Bushnell BD et al: Malunion of the distal radius. J Am Acad Orthop Surg. 15(1):27-40, 2007
                                                  18. Huckstadt T et al: Pediatric fractures of the carpal scaphoid: a retrospective clinical and radiological study. J Pediatr Orthop. 27(4):447-50, 2007
                                                  19. Price CT et al: Osteotomy for malunited forearm shaft fractures in children. J Pediatr Orthop. 26(2):193-6, 2006
                                                  20. Anderson SE et al: MR imaging of avascular scaphoid nonunion before and after vascularized bone grafting. Skeletal Radiol. 34(6):314-20, 2005
                                                  21. Gicquel P et al: Problems of operative and non-operative treatment and healing in tibial fractures. Injury. 36 Suppl 1:A44-50, 2005
                                                  22. Khoshhal KI et al: Physeal bridge resection. J Am Acad Orthop Surg. 13(1):47-58, 2005
                                                  23. Papadimitriou NG et al: Post-traumatic cystic lesion following fracture of the radius. Skeletal Radiol. 34(7):411-4, 2005
                                                  24. Ecklund K et al: Patterns of premature physeal arrest: MR imaging of 111 children. AJR Am J Roentgenol. 178(4):967-72, 2002
                                                  25. Waters PM et al: Surgical management of posttraumatic distal radial growth arrest in adolescents. J Pediatr Orthop. 22(6):717-24, 2002
                                                  26. Ecklund K et al: Imaging of growth disturbance in children. Radiol Clin North Am. 39(4):823-41, 2001
                                                  27. Goldfarb CA et al: Wrist fractures: what the clinician wants to know. Radiology. 219(1):11-28, 2001
                                                  28. Cerezal L et al: Usefulness of gadolinium-enhanced MR imaging in the evaluation of the vascularity of scaphoid nonunions. AJR Am J Roentgenol. 174(1):141-9, 2000