Physiological periostitis versus Trampoline Injury-Plain Xray

Young child of 3 years with  trampoline injury (most common). Resident-Professor series by Dr MGK Murthy.

1. How do you read it?

AP is unremarkable

Lateral suggests symmetrical periosteal response

In view of history of trauma, it could suggest traumatic etiology

2. why not physiological periostitis of children?

Good question

Periosteum is biologically active in children throughout , but physiological periostitis(PP)  is known to occur exclusively in infants between 1- 6months only

3. How to confirm PP?

Simple  we follow law of two and do other  side X ray.

4. What about the stippled epiphysis both edges?

Since it is symmetrical and no physis is widening is suggested, it is likely to represent normal  growth process. Moreover the physis is not widened

5. Any other lesson to carry from this radiograph?

§  we need to keep the age of injury in mind and if it is more than 7 days, infective etiology needs to be kept in mind

§  dating of fractures in children is inexact science as brought out by extensive review in AJR.

§  Reasonable conclusion could be periosteal response could be seen as early as 4 days and is  present in at least 50% by 2 weeks  ,and remodeling peaks by 8 weeks

§  If there is associated corner or bucket handle fracture, child abuse needs consideration(10% of children younger than 5 years, brought to emergency room are victims of child abuse )