Pediatric Radiology

https://doi.org/10.1007/s00247-019-04591-2

REVIEW

Describing pediatric fractures in the era of ICD-10

Tal Laor 1 & Roger Cornwall 2

Received: 10 September 2019 / Revised: 8 November 2019 / Accepted: 26 November 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Childhood fractures are extremely common. The recent trend is to direct certain fracture care from orthopedic specialists to
primary care clinicians. However, to confirm an appropriate level of treatment, the initial diagnosis must be accurate, the
description precise, and the communication between those caring for the child consistent. This review illustrates descriptors
used at one institution that are based on terminology consensually created between radiologists and orthopedic surgeons for
common pediatric fracture types and their displacement, and that satisfy the expanded and detailed International Statistical
Classification of Diseases and Related Health Problems (ICD)-10 requirements for successful coding.

Keywords Bones . Children . Classification . Description . Extremity . Fracture . Radiography . Trauma

Introduction correct. This is particularly important given recent recommen-

Fractures in children are very common, with approximately
one-third of children sustaining a fracture before the age of
17 years. Children older than 2 years are generally very active
and partake in various activities that result in fracture, with
injuries of the forearm being most common [1]. Most injuries
result from low-velocity trauma and follow simple fracture
patterns. Physeal fractures can be more challenging to diag-
nose and treat and can lead to substantial growth disturbance.
Prior to the age of 2 years, fractures frequently are the result of
inflicted trauma [2].
Treatment of fractures ranges from splinting, to bracing or
casting without or with specialty follow-up, to urgent reduc-
tion and surgical fixation [3]. Optimal therapy plans follow
specific treatment patterns, and although management can dif-
fer among clinicians, the treating physician, patients and fam-
ily members must be aware of potential early and late compli-
cations that ultimately affect outcomes [3]. To provide appro-
priate treatment, it is crucial that the initial diagnosis be
* Tal Laor
tal.laor@childrens.harvard.edu
1
Department of Radiology, Boston Children’s Hospital,
300 Longwood Ave., Boston, MA 02115, USA
2
Division of Pediatric Orthopaedics, Cincinnati Children’s Hospital
Medical Center, Cincinnati, OH, USA
dations for only symptomatic treatment of simple fractures
such as buckle fractures of the distal radius [4–9], with no
follow-up after the emergency department visit [10] or
follow-up only with primary care providers [11, 12].
Although orthopedic specialists typically review radiographic
images themselves, less specialized providers such as emer-
gency department or primary care physicians might rely solely
on the written report of the radiologist (pediatric or other) to
determine diagnosis and thus the definitive treatment and
follow-up plan. This scenario, increasingly relevant in the
era of cost containment [13], makes the accuracy of radiologic
description particularly important because subtly different
fractures can behave very differently [14]. In addition, com-
munication among those caring for patients — including ra-
diologists; emergency department, urgent care and sports
medicine physicians; and orthopedic surgeons — must be
consistent, with uniform terminology.
The International Statistical Classification of Diseases and
Related Health Problems (ICD) system developed by the
World Health Organization (WHO) is a method used to eval-
uate disease morbidity and mortality. The National Center for
Health Statistics, under WHO authorization, created a clinical
modification (CM) for the ICD system for use by health care
providers in the United States. The 10th version (ICD-10-CM)
of this cataloging system took effect Oct. 1, 2015, and is used
by health providers, coders, insurance carriers and govern-
ment agencies to record health disorders, track disease trends,
and aid in reimbursement. The transition from ICD-9-CM to

ICD-10-CM resulted in a great expansion of the number of
codes and specificity required for complete documentation,
particularly with respect to fracture description.
The most recent version of the ICD guidelines requires re-
ports to delineate the following information: timing of patient
encounter and fracture characteristics to include location and
laterality, fracture type, open or closed, displacement if any,
and stage of healing [15]. The basic structure of the ICD-10
coding is based on seven alphanumeric characters. The first
character for fractures is always an S, which signifies that the
code is for an injury rather than another category of pathology,
such as pneumonia or bowel obstruction. The subsequent sec-
ond through sixth characters in a given combination denote
fracture attributes. Each character does not represent a specific
characteristic, but rather the combination of characters indicates
the required fracture descriptors such as bone involved, portion
of the bone, laterality, type of fracture, and displacement. The
seventh and final character is a place-holder used to increase
specificity. For example, various seventh characters describe
whether a fracture is open or closed (if an initial encounter); if
the fracture shows routine healing, delayed healing or non-
union (if a subsequent encounter); or sequelae of fracture (if a
more remote encounter). Examples of ICD-10 code characters
are shown in Tables 1 and 2 [16]. If the necessary information
for correct fracture coding is not available in the dictated report,
manual coders are required to search the medical record for the
obligatory information. A recent report noted a decrease in
unspecified and therefore incomplete ICD-10 coding following
the implementation of a standard report for fracture description
from 43% to 27% at the termination of the study [17].
With these current reporting requirements for complete
ICD-10-CM coding and changing norms for fracture manage-
ment, it has become even more imperative that descriptive
language used for conventional radiography reports be consis-
tent and concise. To this end, an institutional collaborative
effort was put forth between the Department of Radiology
and the Division of Orthopaedic Surgery at our hospital to
compile a comprehensive, shared descriptive vocabulary to
Table 1 International Statistical
Classification of Diseases and ICD-10 code (first 3 characters)
Related Health Problems (ICD)-
10 codes (1st–3rd characters, S00–09
range and location of injury)a S10–19
S20–29
S30–39
S40–49
S50–59
S60–69
S70–79
S80–89
S90–99
a
Modified from [16]
Pediatr Radiol
be used in the diagnosis, description and treatment evaluation
of common fracture patterns that affect children, and to assure
compliance with the ICD-10 coding standards. This review
illustrates the common pediatric fracture types, delineates the
fracture descriptors needed to fulfill the ICD-10-CM coding
requisites based on a departmental practice, and presents our
institution’s consensual terminology.
Patient encounter
In most cases, whether the radiographic examination is an initial
or a subsequent evaluation of a fracture should be delineated in
the radiology report in the “clinical history” or “indication” field
for a given examination. An encounter is considered subse-
quent if the child is receiving routine care for the fracture during
the healing or recovery phase [18]. If applicable, specification
of comparison study date(s) can be used to indicate a follow-up
evaluation. In some instances, a visit might be for sequela or
late effects from a prior fracture, such as growth arrest or infec-
tion, and if so, should be stated as such.
Fracture location and laterality
The bones affected and whether the fracture is of a right or left
limb, when applicable, usually is best described in the proce-
dure comments/technique portion of the report. Additional
description of the fracture most often is placed in the findings
component of a report.
The location of a fracture within a given bone of a growing
child can reflect the changing composition of bone, the type of
injury sustained, and direct appropriate acute treatment, and it
can determine possible long-term consequences [19].
Different portions of bone and their susceptibility to injury
change with the physiological and biomechanical demands
during skeletal maturation [20]. Following the postnatal peri-
od, the diaphysis or central shaft becomes composed of
Description
Injuries to the head
Injuries to the neck
Injuries to the thorax
Injuries to the abdomen, lower back, lumbar spine, pelvis
Injuries to the shoulder and upper arm
Injuries to the elbow and forearm
Injuries to the wrist, hand and fingers
Injuries to the hip and thigh
Injuries to the knee and lower leg
Injuries to the ankle and foot
Pediatr Radiol

Table 2 International Statistical

Classification of Diseases and
Related Health Problems (ICD)-
10 codes: examples of 7th
character and associated
description for fracturesa
ICD-10 code (7th character) Description
A Initial encounter for closed fracture
C Initial encounter for open fracture not otherwise specified (NOS)
D Subsequent encounter for closed fracture with routine healing
G Subsequent encounter for closed fracture with delayed healing
K Subsequent encounter for closed fracture with nonunion
P Subsequent encounter for closed fracture with malunion
S Sequela
Example code
S72.321A = Displaced transverse fracture of the shaft of the right femur, initial encounter for closed
fracture
The following information was revealed by the characters in the code:
- Fracture (i.e. not a pneumonia)
- Closed
- Femur
- Right side
- Transverse fracture
- Displaced
- Initial encounter
a
Modified from [16]

mature or lamellar bone with continually changing haversian

systems that respond to mechanical stresses. As the child
grows, the diaphyseal bone becomes less vascular, more
dense, and thus less compliant. The metaphysis is the flared
portion of bone located immediately adjacent to the physis. It
has a much thinner cortex than the diaphysis and is composed
of immature bone or the primary spongiosa. This is the site of
the most newly created trabeculae that have formed as the
result of endochondral ossification. The more mature second-
ary spongiosa, which is closer to the diaphysis, is the site of
substantial bone turnover and remodeling. Similar to the di-
aphysis, the metaphysis undergoes alterations during skeletal
growth. The cortex of the metaphysis is thinner than the di-
aphysis and has more fenestrations that contain fibrovascular
tissue [20]. There is a relatively long smooth transition be-
tween the metaphysis and the diaphysis. This site is referred
to as the metadiaphysis (Fig. 1). At this transition between the
thicker diaphyseal and thinner metaphyseal cortex, the bone is
prone to failure. Therefore, the metadiaphysis is the most fre-
quent site of incomplete fractures, such as the buckle fracture,
as well as complete fractures. The skeletal changes with
growth, namely a decrease in cortical fenestrations and an
increase in cortical thickness, are reflected in the subsequent
fracture morphology. This change in bone composition results Fig. 1 Normal lateral forearm radiograph in a 4-year-old boy. The
transition zone (bracket) between the thicker diaphyseal cortex (thick
in the metadiaphyseal zone of transition between the arrow) and the thinner metaphyseal cortex (thin arrow), referred to as
metaphysis and the diaphysis moving closer to the adjacent the metadiaphysis, is prone to failure and therefore is a frequent location
physis, and therefore, so does the location of fracture [21]. of fracture

Fig. 2 Plastic deformation of the radius in a 6-year-old boy who fell on an
outstretched upper extremity. a Initial lateral radiograph of the forearm
shows apex anterior bowing of the radius (arrow) without cortical
disruption and an oblique fracture of the distal diaphysis of the ulna. b
Lateral radiograph obtained 6 weeks after the injury shows smooth
periosteal new bone formation along the bowed radius (arrow),
consistent with a healing plastic deformation injury. There is periosteal
new bone formation with callus around the ulnar fracture that reflects
routine healing
Type of fracture
The most commonly encountered pediatric fractures include
those considered incomplete (such as plastic deformation, buck-
le and greenstick), complete, physeal, comminuted, bucket-
handle or corner metaphyseal, pathological and stress-related.
Incomplete fracture
Plastic deformation
Plastic deformation of bone is specific to children, particularly
young children, and was initially described by the German anat-
omist Augustus Rauber in 1876 [22, 23]. In this early explana-
tion, Rauber noted that a large enough compressive force on a
bone would leave a deformity of bone after removal of that force
[23]. Plastic deformation of bone usually affects the diaphysis
and occurs when a stress on bone exceeds the elastic limit, with
the acute deformity considered irreversible [20, 24]. Although
the cortex appears radiographically intact, it presumably has
sustained microfractures [20] (Fig. 2). If the force is further
Pediatr Radiol
increased, a discrete fracture will occur [24]. Because of the
composition of pediatric bone cortex, which includes its pattern
of relatively less mineralization and increased cortical vascular-
ity [20], a bone in a child can absorb more energy before the
force results in a fracture than a bone of an adult [23].
The bones that most commonly sustain plastic deformation
include the ulna, radius and fibula. Uncommonly, the femur
sustains plastic deformation [20]. Although initial radiographs
show no cortical disruption, follow-up imaging often, but not
always, reveals periosteal new bone formation from fracture
healing. This fracture also has been referred to as a “bowing
fracture”; however, as long bones can appear bowed during
normal development, the term plastic deformation is preferred
to refer to an irreversibly bowed bone without obvious fracture.
Sometimes plastic deformation is subtle and is detected only
with comparison to the unaffected side. If the child is young
(usually younger than 4 years) when the injury occurs, and the
bowing of bone shows angulation less than 20°, the deformity
usually corrects with normal skeletal growth [23].
Buckle fracture
The definition of a buckle fracture is very strict and specific
and the term should be used carefully. A buckle fracture is an
incomplete fracture at the junction of the thin metaphyseal
cortex and thick diaphyseal cortex along the compressive side
of bone. This metadiaphyseal deformity results in a unicortical
bulge radiographically that does not extend across the entire
diameter of bone and shows no evident cortical disruption
[25]. There is a zone of normal bone morphology between
the fracture and the adjacent physis (Fig. 3). However, despite
the buckling of bone seemingly localized on initial imaging,
on follow-up radiographs there might be a transverse band of
increased radiodensity across the entire width of the bone [25].
Soft-tissue swelling might be absent because of a lack of mac-
roscopic cortical disruption. This injury is most commonly
seen in the distal radius as the result of a fall on an outstretched
hand, the so-called FOOSH mechanism. True buckle fractures
are considered clinically stable and are treated with short-term
casting or bracing [3]. Radiographic follow-up for buckle frac-
tures (and not other types of fractures with a buckle-like com-
ponent) is generally considered unnecessary and orthopedic
specialty referral is not required [26]. However, it must be
noted that more severe fracture types, such as physeal injuries,
can have buckling of a cortex as a part of the fracture pattern.
These fractures require specific orthopedic care. Therefore,
the presence of buckling of the cortex does not preclude a
more serious injury.
Historically, the term “torus fracture” has been used to de-
scribe a buckle fracture. This term is considered inaccurate
because the word “torus” is derived from Latin, meaning
swelling or protuberance, and refers to a geometric surface
generated in three-dimensional space about an axis coplanar
Pediatr Radiol

Fig. 3 Buckle fractures of the

distal forearm in a 9-year-old girl
who fell on an outstretched upper
extremity. a Anteroposterior
radiograph of the distal forearm
shows a buckled contour to the
distal radial and ulnar
metadiaphyses without cortical
disruption (arrows). b An oblique
radiograph shows the cortical
buckling of both bones along the
dorsal (compressive) side of the
bone (arrows). Note the normal
contour of the distal bones
adjacent to the distal physes

with the circle. This path results in a ring shape like an inner
tube, bagel or donut [27]. A buckle fracture, which affects the
compressive side of the bone, does not result in a circumfer-
ential torus bulge, and thus the term “torus” is imprecise.
Recent literature suggests that in children ages 7–16 years an
isolated distal radial fracture located within 1 cm of the distal
physis is unlikely to be a buckle fracture [28].
propagate completely, with resultant plastic deformation of
the compression side [3]. A greenstick fracture occurs at the
metadiaphysis of the long bone, where the cortex transitions
from being thicker in the diaphysis to thinner in the
metaphysis. It also can occur in the diaphysis. This fracture
classically results from a compression and rotational force
[29].

Unicortical failure Other unicortical failure. If the unicortical failure is evident on

Greenstick fracture. A greenstick fracture is an incomplete
fracture with a radiographically evident cortical disruption that
begins on the tension side of the bone (Fig. 4) [2] but does not
the compression side of bone (same location as a buckle
fracture), this injury is not a greenstick fracture but can be
referred to as an “incomplete fracture with cortical disrup-
tion,” essentially representing a “broken buckle fracture”
(Fig. 5).

Fig. 5 Incomplete fracture with cortical disruption of the distal radial

Fig. 4 Greenstick fracture of the distal radius in a 6-year-old boy. a, b
Anteroposterior (a) and lateral (b) radiographs of the distal forearm show
a fracture of the distal radial metadiaphysis on the tension side. The cortex
of the compressive side of the radius (arrow) remains intact
metadiaphysis in a 5-year-old boy. a, b Radiographs of the distal
forearm show buckling of the distal radial metadiaphysis in the
anteroposterior projection (a), and cortical discontinuity along the
compression side (arrows) on the lateral view (b). The dorsal cortex
(tension side of the bone) appears intact

Complete fracture
If a fracture propagates through a bone, it is termed a complete
fracture [2]. There are various configurations of complete frac-
tures; these include transverse, oblique and spiral fractures,
based on the mechanism of injury. A transverse fracture runs
approximately perpendicular to the shaft of bone as the result of
a perpendicular force such as occurs during bending (Fig. 6).
An oblique fracture has a diagonal course, usually across the
diaphysis, at approximately 30–45° to the axis of the shaft, and
is related to a longitudinal compressive force (Fig. 6). A spiral
fracture encircles a bone in a twisting fashion, similar to a
corkscrew [19], and thus might be seen to propagate along a
longer segment of bone viewed in orthogonal planes (Fig. 6). A
spiral fracture most commonly is the result of a rotational force
on the bone, usually from a low-velocity injury. This type of
fracture can be seen in the setting of child abuse [2]. A spiral
fracture is associated with an intact periosteum, and thus can be
reduced when a reversed rotational force is applied [2].
Physeal fracture
Fractures that involve the physis make up approximately 15–
18% of all pediatric fractures [30]. Although numerous sub-
sequent classifications of fractures have involved the physis
and periphyseal structures, the system proposed originally by
Salter and Harris [31] remains most commonly used. The
original Salter–Harris classification is based on five patterns
of fracture and their ultimate prognosis. They are as follows:
Type I is a fracture that courses through and remains entirely
within the physis, resulting in separation of the epiphysis from
the metaphysis (Fig. 7). This is most common in infants and
Fig. 6 Complete fractures. a Anteroposterior (AP) radiograph in a 9-year-
old girl with a transverse fracture of the distal radial metadiaphysis. There
also is buckling (arrow) of the distal ulnar metadiaphysis. b Lateral
radiograph in a 6-year-old boy with an oblique fracture of the distal
radial diaphysis. c AP radiograph in a 2.5-year-old boy with a spiral
fracture of the tibia
Pediatr Radiol
younger children, who have thicker and less undulating
physes, and can be radiographically silent. Salter–Harris
Type II is the most common type of physeal fracture.
Although it courses through the physis, a portion of the frac-
ture plane extends through the adjacent metaphysis, creating a
separate metaphyseal fragment known as the Thurstan
Holland fragment (Fig. 8). A Salter–Harris Type III physeal
fracture exits through the adjacent epiphysis, forming an
intraarticular fracture (Fig. 9). In addition to possible growth
arrest, Type III fractures can result in post-traumatic arthritis if
there is substantial distraction or step-off at the articular sur-
face. Instead of coursing along the physis, the Type IV fracture
crosses the physis and thus involves both the adjacent
metaphysis and epiphysis (Fig. 10). The triplane fracture of
the distal tibia is usually considered a variation of the Salter–
Harris Type IV fracture, with sagittal, axial and coronal frac-
ture planes that extend from the metaphysis, through the
physis, to the epiphysis. The Type IV fracture thus might
result in acute longitudinal instability, eventual physeal arrest
and ultimately growth deformity. Type V classically describes
a crush-type injury to the physis. This form of physeal injury
might not be radiographically apparent and its existence has
been questioned [30]. Although the Salter–Harris classifica-
tion is not comprehensive, it does offer a foundation for frac-
ture recognition and evaluation because it is simple and can be
applied widely [30].
The prognosis of a Salter–Harris fracture is multifactorial
and depends on several variables, which include but are not
limited to type of fracture and mechanism of injury, age of the
Fig. 7 Salter–Harris Type I fracture of the distal femur in a 1-day-old boy
with history of polyhydramnios, ligamentous laxity and multiple
congenital anomalies. Coronal ultrasound image of the distal right
femur shows lateral translation of the cartilaginous femoral epiphysis
(asterisk) from the distal femoral metaphysis (dashed arrow) as a result
of a physeal fracture. There is uplifting of the periosteal/perichondrial
complex (solid arrow) at the level of the physis from the underlying bone
Pediatr Radiol

Fig. 8 Salter–Harris Type II fracture of the thumb in a 14-year-old boy.

Anteroposterior radiograph of the thumb shows the Thurstan Holland
fragment, a metaphyseal component (solid arrow) of the proximal
fracture fragment, offset from the remainder of the thumb (dotted
arrow) at the level of the physeal fracture Fig. 9 Salter–Harris Type III fracture of the distal tibia in a 12-year-old boy.
Oblique radiograph of the ankle shows the epiphyseal (solid arrow) and
physeal (dashed arrow) components of a Salter–Harris Type III fracture. In
patient, initial fracture displacement, method and success of the distal tibia, this type of injury also is known as a Tillaux fracture. This
reduction, and amount of intraarticular displacement. Any of fracture usually happens around the time of physeal closure, which begins in
the anteromedial tibia. The lateral portion of the tibial physis remains patent
the Salter–Harris fractures that disrupt the germinal zone of longer, and therefore is prone to fracture propagation
the physis directly, or affect the adjacent epiphyseal or
metaphyseal blood supply to the physis can result in growth
disturbance. In particular, the location of the physis within the
body is a very important prognostic factor [30].
In 1994, Peterson expanded the classification of fractures
based on a large epidemiologic assessment of physeal injuries
[32] and described variants of injuries he encountered that
were not included in the original Salter and Harris fracture
scheme. These variations included the distinct patterns named
Peterson Types I and VI [33]. Peterson Type I is a
metadiaphyseal fracture with longitudinal extension to, but
not traversing along, the physis; Peterson Type VI is a loss
of part of the physis and epiphysis, often including the artic-
ular surface [33], described as a “lawnmower” variety injury
[30]. The Peterson Type I fracture often shows sclerosis in a
triradiate-type pattern while healing, with two horizontal or
oblique limbs and a perpendicular or longitudinal component
parallel to the axis of the bone (Fig. 11). This pattern of frac-
ture components is likened to the emblem associated with the
Mercedes-Benz brand, with the longitudinal component locat-
ed within the dorsal half of the radius. The Peterson Type I
fracture, also referred to as a Salter–Harris Type II variant, Fig. 10 Salter–Harris Type IV fracture of the distal radius in a 15-year-old
girl. Posteroanterior radiograph shows a fracture lucency that courses distally
should not be mistaken for a buckle fracture (if the longitudi- from the radial metadiaphysis across the physis to the articular surface without
nal component extending to the physis is unrecognized) and substantial distraction or step-off at the articular surface (arrow). Additionally,
erroneously result in lack of appropriate follow-up care. there is a minimally distracted ulnar styloid fracture
 Pediatr Radiol

Fig. 11 Peterson Type I distal

radius fracture in an 8-year-old
girl. a, b Posteroanterior
radiograph of the distal wrist
without (a) and with (b) dotted
lines demarcating the transverse
and longitudinal components of
the fracture that extend to but do
not involve the distal radial
physis. c Lateral radiograph of the
wrist shows the discontinuity of
the dorsal cortex (arrow)
demarcating the proximal extent
of the longitudinal component of
the fracture. d Four weeks later,
sclerosis of the fracture lines is
visible (arrows)

Although physeal growth arrest is very uncommon, continued

follow-up through healing is warranted.

Comminuted fracture

A comminuted fracture is composed of multiple fracture

planes that propagate in different directions and result in three
or more fracture fragments of varying sizes (Fig. 12). This
type of fracture is atypical in younger children but becomes
more common in adolescents and usually results from multi-
directional forces of injury [19].

Bucket-handle or corner fracture

The bucket-handle or metaphyseal corner fracture is a highly

distinctive injury and is often the basis for the diagnosis of
child abuse [34, 35]. This fracture, thought to be the result of Fig. 12 Comminuted fracture of the fibula in an 8-year-old boy.
violent shaking as an infant is held by the extremities or trunk Anteroposterior radiograph shows multiple fragments that comprise the
[36] or from a shearing force, is characterized by a fracture mid-diaphyseal comminuted fracture
Pediatr Radiol

plane that courses through the most immature portion of

metaphyseal bone, immediately adjacent to the physis, in an
area that includes the relative weak primary spongiosa and
intervening calcified matrix. As the fracture courses toward
the periphery of bone, it undermines a bony metaphyseal frag-
ment, forming the classic metaphyseal lesion [37]. The resul-
tant metaphyseal fracture fragment is a variable-size — albeit
thin — disk centrally that becomes thicker at its peripheral
margin [34, 35, 37]. Thus one component of the fracture in-
cludes the epiphysis, the adjacent physis, and a thin segment of
metaphyseal bone with its peripheral bony collar, and the other
component is the remainder of the bone. Radiographically, the
appearance of this metaphyseal fracture depends on the plane of
projection. When viewed obliquely, this thin disk resembles an
arc-like bucket-handle, and when viewed on end or tangential-
ly, the discrete peripheral fragments are most evident and ap-
pear as corner fractures (Fig. 13). In reality, these corner frac-
tures are continuous, with the thin disk of metaphyseal bone.
There is variable disruption of periosteum, and periosteal new
bone formation is not always present in the healing phase [37].
These fractures are considered highly specific for child abuse
[35] and are the most frequently encountered truly metaphyseal
fractures coursing immediately subjacent to a physis. Fig. 14 Pathological fracture of the humerus in a 15-year-old boy.
Oblique radiograph of the right arm shows a pathological fracture that
traverses a cystic lesion (arrow) of the mid-humeral diaphysis
Pathological fracture

A pathological fracture occurs in bone that is weak, with al-
tered or reduced mechanical and viscoelastic properties. The
bone abnormality can be focal, such as with an underlying
lesion (Fig. 14), or diffuse from a systemic abnormality
(Fig. 15) [38]. In general, a pathological fracture is caused
by a minor trauma that normally would not result in a fracture
[38]. The fracture might be the initial sign of underlying
pathology, which in children most often is the result of a
benign etiology, such as a unicameral bone cyst, non-
ossifying fibroma or bone infection. Pathological fractures
can also complicate less commonly encountered malignant
lesions. Other bone diseases, such as osteogenesis imperfecta,
and neuromuscular disorders can result in pathological frac-
tures [38].

Fig. 13 Bucket-handle fracture in

a 3-week-old boy. This distal
tibial metaphyseal fracture was
the result of child abuse. a
Anteroposterior radiograph of the
ankle shows a metaphyseal
fracture of the distal tibia that
resembles a bucket handle
(arrow). b Lateral radiograph of
the same ankle shows that the
metaphyseal fracture undermines
the periphery of the metaphysis
(arrow), resulting in a corner
fracture appearance
 Pediatr Radiol

of narrower bones, relatively decreased mineral content, and

the effect of changing hormones [39].
A stress injury, usually from a chronic and repetitive work-
load in an older child or the onset of walking in a toddler [39],
results in a responsive or reparative bone reaction. This might be
radiographically silent initially and eventually manifest as an area
of focal sclerosis (Fig. 16). If located in the shaft of a long bone,
smooth periosteal new bone formation might be visible. This is
termed “stress response.” The term stress fracture is reserved for
stress injuries that have resulted in macroscopic fracture of bone
and these are usually evident when the healing response has
begun (Fig. 17). There can be overlap between describing an
injury as a stress response or as a healing stress fracture.

Open or closed fracture

ICD-10 coding requires determination of whether a fracture is

Fig. 15 Pathological fracture of the distal femur in an 18-month-old boy
with osteogenesis imperfecta. Lateral radiograph of the right lower
extremity shows an acute Salter–Harris Type II fracture of the distal
femur (arrow). The femur and tibia are bowed as a result of prior fractures
Stress fracture
Stress injuries in children are the result of chronic mismatch
between the intrinsic biomechanical properties of bone and the
load of activity placed upon the growing musculoskeletal sys-
tem [39]. Growing children are particularly prone to stress
injuries because of relative weak chondro-osseous junctions,
increased activity, relatively less muscle mass, thinner cortices
open or closed. Open fractures that are associated with and clas-
sified in part by the extent of disruption of skin and soft tissues
are uncommon [40]. In children, open fractures comprise less
than 2% of all fractures. If a fracture is open, it should be de-
scribed clearly in the radiology report. If the fracture is not spe-
cifically documented as open or closed, the coders are instructed
to code the fracture as closed. This differentiation, unless clearly
evident on imaging, can be based on the clinical information, if
provided. A fractured bone might appear entirely within the soft-
tissue envelope on imaging even when it was transiently outside
the skin at the time of injury. Therefore, one should not assume a
fracture to be closed based on imaging alone.
Displacement
Displacement of a fracture describes the difference between
the normal position expected in an unaffected bone and the

Fig. 16 Stress injury of the foot in

a 4-year-old boy who presented
with a limp. a The boy had
developed disuse osteoporosis
following 3 weeks of non-
weightbearing for an initial
diagnosis of an occult toddler
fracture of the tibia. There is a
crescentic area of sclerosis of the
posterior calcaneus (arrow) on a
lateral radiograph of the hindfoot,
consistent with a stress injury. b
Lateral radiograph from the same
boy at the time of initial
presentation, in retrospect, shows
vague crescentic sclerosis of the
posterior calcaneus (arrows)
Pediatr Radiol
Fig. 17 Healing stress fracture of the tibia in a 13-year-old boy. Lateral
radiograph of the tibia shows horizontal sclerosis and smooth focal
periosteal new bone formation of the proximal tibial metadiaphysis,
indicative of a healing stress fracture
abnormal position of the bone and its components. A fracture
can be non-displaced. When displaced, the fracture description
should include three characteristics — type, direction and
magnitude — using institutional-based preferred terminology.
Fig. 18 Displaced index finger fracture in a 20-year-old man with
decreased range of motion. a Preoperative lateral radiograph of the
index finger shows an intraarticular fracture at the base of the middle
phalanx. Dorsal subluxation relative to the proximal phalanx is subtle.
b, c Sagittal reformatted CT images show a displaced intraarticular
fracture at the base of the middle phalanx in (b) and (c), which
The various types of displacement include translation, an-
gulation, shortening or distraction, and rotation. Translation
refers to motion in a sideways plane. Direction of translation
can be described using terms such as medial, lateral, dorsal,
volar, plantar, palmar, anterior and posterior. Because the use
of medial or lateral in the hand and wrist can cause confusion,
radial or ulnar are preferred descriptors. When the fracture is
non-articular, the translation is quantified by percentage of the
adjacent width of the normal bone. For example, a fracture
fragment might be described as translated laterally by 30%.
Based on institutional consensus, we avoid describing trans-
lation in millimeters. However, when the fracture extends to
the articular surface, we use a numeric measurement in milli-
meters to quantify the distraction or step-off. Additionally, if
there is intraarticular extent of fracture, there should be mention
of joint alignment. For example, a joint remains concentric
when both major components are normally located, but the joint
might also be subluxated or dislocated (Fig. 18).
Angulation, another form of displacement, is the angle
formed between bone fragments, and is described by location
of the apex (Fig. 19). The angulation might be, for example,
apex radial or ulnar, anterior or posterior, superior or inferior,
or varus or valgus, referring to the direction of “the point.” The
extent of angular displacement can be quantified by degrees.
A distal radial metadiaphyseal transverse fracture, for exam-
ple, might be described as showing 40° of apex anterior
emphasizes that the distal aspect of the proximal phalanx (solid circle)
and base of the middle phalanx (dotted circle) are no longer congruent. d
Postoperative lateral CT following open reduction and percutaneous
pinning shows improved alignment and proximal interphalangeal joint
congruity
 Pediatr Radiol

Fig. 20 Shortening in a displaced left clavicular fracture in a 15-year-old

boy. Anteroposterior radiograph obtained with 15° of cephalad
angulation shows a left mid-clavicular fracture. In addition to greater
than 100% inferior translation, there is approximately 2 cm of
shortening or overriding (arrow) between the fracture components

severity and corresponding terms should be reached and used

Fig. 19 Angulated distal radial fracture in a 5-year-old girl. Lateral wrist
radiograph shows a distal radial metadiaphyseal fracture with
approximately 35° of apex volar angulation (lines, arrow)
consistently. However, subjective descriptors can result in
undertreatment or unnecessary alarm if there is discrepancy
between the clinical and radiographic criteria.
Shortening refers to the displacement of fracture fragment
showing overriding or collapse of components, and this is
described in millimeters or centimeters (Fig. 20). Similarly,
distraction is the measure of how far apart two fragments are
when measured in a similar axis (Fig. 21). Distraction is com-
monly used to describe the displacement of an avulsion injury.
Rotation can be difficult to appreciate on two-dimensional
radiographs. One clue to rotation is a width discrepancy be-
tween the fracture components [29]. Description of the

angulation. Use of apex location reduces any confusion or

ambiguity of fracture fragment positioning. Caution should
be used with subjective terms such as mild, moderate or se-
vere, which might be misinterpreted as not needing treatment
or referral, when clinically a fracture might be deemed unsta-
ble. The initial angulation of a fracture is only one character-
istic driving treatment decision-making, and subjective terms
such as “mild” or “minimal” can lull the ordering provider into
thinking that the fracture as a whole does not require careful
treatment. Furthermore, the definitions of mild, moderate and
severe vary based on the location and type of the fracture. For
instance, 15° of apex volar angulation of a distal radius frac-
ture in a 3-year-old child would be considered mild, whereas
15° of varus or valgus angulation of a distal femur Salter–
Harris Type II fracture in the anteroposterior image would
be considered severe. Similarly, 5 mm of translation of a
midshaft femur fracture in an infant would be considered mild,
whereas 5 mm of translation of an intraarticular phalangeal
fracture would be considered severe. Therefore, we prefer
not to advocate for universal definitions of mild, moderate Fig. 21 Displaced patellar sleeve fracture in a 9-year-old boy. Lateral
and severe. If qualitative terms are preferred by the orthopedic radiograph of the flexed knee shows approximately 3 cm of distraction
surgeons, a general consensus with the radiologists regarding (arrow) of the fracture fragment from the inferior pole of the patella
Pediatr Radiol
Fig. 22 Healing tibial fracture in a 14-year-old boy. Lateral radiograph of
the leg shows a transverse fracture of the distal tibial diaphysis. There is
approximately 20° of apex posterior angulation and approximately 20%
posterior translation of the distal fragment. Periosteal new bone formation
reflects early routine healing. A non-displaced oblique fracture of the
distal fibular metadiaphysis does not yet show periosteal new bone
direction of rotation should use anatomical terms such as ex-
ternal or internal, supinated or pronated, but rotation can also
be described in terms of angulation when the three-
dimensional movement is not clear.
Healing
The ICD-10 coding requires mention of the stage of fracture
healing. Radiographs of a fracture might show an acute
Fig. 23 Sample standard report
for pediatric fractures that satisfies
International Statistical
Classification of Diseases and
Related Health Problems (ICD)-
10 coding requirements (the
fracture is not described as open
and thus is assumed to be closed)
fracture at an initial encounter, and thus no signs of early
healing. Alternatively, the fracture when not imaged acutely
might be described as showing radiographic findings of early
or continued routine healing (Fig. 22). Signs of routine healing
include callus and periosteal new bone formation, and changes
of the fracture lucency, either with early resorption and in-
creased lucency or later indistinctness, followed ultimately
by radiographic resolution. Complications of fracture healing
include delayed healing, non-union or malunion. If a fracture
is no longer evident but the radiographs were obtained to
evaluate that injury, the phrase “no signs of ongoing healing
process” is used. The term “healed” is avoided to reflect pos-
sible discrepancy between radiographic and clinical union.
Conclusion
The impact of what is reported cannot be stressed enough,
particularly when the radiographic report is read by the non-
orthopedic clinician. Therefore, precise description and appro-
priate terminology are paramount because the radiology report
is frequently the vehicle that directs subsequent care. Injuries
such a buckle fractures have a very strict definition, are con-
sidered clinically stable and usually do not require specialty
referral or radiographic follow-up [26]. However, injuries that
are considered unstable or fractures that involve the physis
should be referred for orthopedic follow-up to evaluate for
subsequent complication such as growth arrest that might ne-
cessitate further timely treatment. Quantification of fracture
displacement can help to determine the need for reduction
and might affect timing for follow-up evaluation. Particular
attention to joint congruity must be addressed with
intraarticular fractures. A sample standard report for pediatric
fractures is presented in Fig. 23. If more than one fracture is

present, each fracture should be described separately in the
report, typically as a separate line or paragraph under each
subheading in the fracture description.
In summary, in addition to the correct description of the
fracture category, the type, direction, and magnitude of dis-
placement should be communicated appropriately. The need
to fulfill all requirements for ICD-10 coding should encourage
the refinement of language used for fracture description be-
tween the radiologist and referring clinicians, which in turn
will allow for comprehensive, consistent and appropriate care.
Acknowledgments We would like to thank Alex Towbin, MD, for his
work in creating the standard fracture report format and Marisela
Camacho, CPC, coding analyst, for her assistance with understanding
ICD-10 coding.
Compliance with ethical standards
Conflicts of interest None
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