What are the appropriate imaging modalities for diagnosing suspected fractures in children?

For diagnosing suspected fractures in children, the primary imaging modality is X-rays ²,³,⁴. There should be a low threshold for same-day X-rays to detect fractures or evidence of bone disease in children, particularly those presenting with an acute limp following trauma ²,³,⁴. This is because a sprain in a child should be considered a possible growth plate injury, as growth plates are more vulnerable to injury than ligaments ²,³,⁴.

In specific circumstances, other imaging modalities are appropriate:

• For children under 16 with a head injury and suspected cervical spine injury, a CT cervical spine scan is indicated if certain risk factors are present, such as a GCS score of 12 or less, intubation, or strong clinical suspicion despite normal X-rays ⁵. If there is neck pain or tenderness but no indications for a CT scan, 3-view cervical spine X-rays may be performed based on specific risk factors like a dangerous mechanism of injury or inability to assess neck movement ⁵. Plain X-rays of the skull should not be used to diagnose important traumatic brain injury ⁵.
• For children under 16 with suspected non-accidental injury, a skeletal survey may be necessary ⁵. X-ray evidence of occult fractures, such as rib fractures in infants, can raise suspicion of child maltreatment ⁶.