Skeletal fractures, a common injury in physically abused children, often go undetected and untreated for significant lengths of time. In such cases, accurate radiographic estimation of time since injury of healing fractures may be essential to identification and characterization of child physical abuse, in both clinical and forensic contexts. However, fracture dating is imprecise in large part because the factors that influence time of healing, particularly in children, are unclear. Scientific, radiographic studies of pediatric fracture healing are limited and often universally applied to patients of all ages and fractures from various locations. Clinical experience and scientific research suggest that a multitude of intrinsic and extrinsic factors influence time of healing, including patient age and fracture location. However, to date, no timelines of pediatric fracture healing accommodate for these variables. This study comprehensively evaluates the effect of patient age and fracture location to time of fracture healing through a retrospective, radiographic study of unintentional long bone fractures of the upper and lower limb in a modern pediatric sample. Findings from this study indicate that patient age and fracture location significantly affect time of fracture healing in children. Children less than two years old exhibited new bone formation significantly earlier and children less than three years old exhibited callus formation significantly earlier. There were significant differences in time of healing between upper and lower limb fractures. SPNBF occurred approximately a week earlier in upper limb fractures and callus formation occurred approximately four days earlier in upper limb fractures. In addition, there were differences in bone type within region, with the larger bones of each region (humerus, femur) reaching hard callus significantly later than other bones within each region. Finally, SPNBF and hard callus were observed significantly earlier in non-diaphyseal compared to diaphyseal fractures. To increase accuracy of radiographic time since injury estimation, timelines of pediatric fracture healing should be specific to patient age and fracture location. Existing timelines of pediatric fracture healing, particularly those based on combined samples of patient ages and fracture locations, should be used with caution and not universally applied.
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