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Updated: May 22, 2026
Assessment of Bone Fracture Healing Using Micro-Computed Tomography
Published on: December 9, 2022
A timetable for the radiologic features of fracture healing in young children
Ingrid Prosser1, Zoe Lawson, Alison Evans
1Department of Paediatrics and Child Health, Cardiff and Vale University Health Board, University Hospital of Wales, United Kingdom.
Insights
Radiologic features help date fractures in children under 72 months. Acute (<1 week), recent (8-35 days), and old (≥36 days) fractures can be identified using key healing signs, aiding child protection decisions.
Area of Science:
- Pediatric Radiology
- Forensic Radiology
- Pediatric Orthopedics
Background:
- Fracture dating in children is crucial for child protection.
- Limited primary evidence exists for fracture healing timelines in pediatric cases.
- Accurate fracture age assessment aids in evaluating injury circumstances.
Purpose of the Study:
- To examine key radiologic features of fracture healing in children.
- To establish timelines for these radiologic features.
- To provide evidence for reliable fracture dating in pediatric patients.
Main Methods:
- Review of 228 digital radiographs from 82 long bone fractures in 63 children (<72 months old) with known fracture timing.
- Independent assessment by three pediatric radiologists of six healing features: soft-tissue swelling, periosteal reaction, soft callus, hard callus, bridging, and remodeling.
- Interobserver agreement analysis using kappa statistics.
Main Results:
- Soft-tissue swelling present days 1-2; periosteal reaction by day 5, prevalent 15-35 days.
- Soft callus visible from day 12, prevalent 22-35 days; hard callus and bridging from day 19, prevalent ≥36 days.
- Remodeling observed in fractures ≥45 days old; good interobserver agreement (kappa 0.55-0.80).
Conclusions:
- Fractures in young children can be reliably dated as acute (<1 week), recent (8-35 days), or old (≥36 days) based on radiologic features.
- The combination of six key radiologic features provides a reproducible method for fracture dating.
- This evidence supports improved decision-making in child protection cases involving pediatric fractures.
Objective:
Fracture dating significantly shapes decisions in child protection. With a dearth of primary evidence underpinning fracture dating in children, we examined the key radiologic features of fracture healing and their timelines.
Materials And Methods:
Digital radiographs of children younger than 72 months old with accidental long bone fractures of known timing were reviewed independently by three pediatric radiologists blinded to the age of the fractures. Six radiologic features of fracture healing were evaluated: soft-tissue swelling, periosteal reaction, soft callus, hard callus, bridging, and remodeling. Interobserver agreement was assessed using kappa analysis.
Results:
Two hundred twenty-eight films of 82 fractures in 63 children (mean age, 4.8 years) were assessed. Soft-tissue swelling was identified by two or more radiologists in 59% of the radiographs at days 1-2 after fractures, and prevalence sharply declined thereafter. Periosteal reaction was first seen at day 5 and was present in 62% of the films obtained between 15 and 35 days after the fracture. Soft callus was first seen at day 12 and was prevalent in 41% between 22 and 35 days. Hard callus and bridging began at day 19, increasing to 60% prevalence from 36 days onward. Remodeling was observed only in fractures 45 days old or more. Kappa scores were between 0.55 and 0.80 overall, with greater agreement when there was no plaster cast.
Conclusion:
The results of this study show that fractures in young children may be dated as acute (< 1 week), recent (8-35 days), or old (≥ 36 days) on the basis of the presence of six key radiologic features in combination. Furthermore, good interobserver agreement suggests these results are reproducible.
