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Case 1: Six year old with leg pain and no history of trauma.
a. Normal right leg radiograph	b. MRI showing diffuse bone bruise distal femur
Case 2: Young woman who plays competitive basketball with complaint of bilateral heel pain.
a. MRI showing bilateral calcaneal stress fractures	b. MRI showing bilateral calcaneal stress fractures
Case 3: Twelve year old gymnast with complaint of “leg pain.”	Case 4: Six year old with complaint of “pain while running.”
MRI showing ischial stress fracture.	MRI showing stress response right tibial shaft.
Case 5: Eleven year old boy with history of right ankle injury, diffuse soft tissue swelling and normal ankle x-rays.	Case 6: Fourteen year old athlete with knee pain.
MRI showing diffuse contusions to the distal tibia, talus and calcaneus.	MRI showing stress fracture proximal tibia.
Case 7: Six year old with a limp.
MRI showing stress fracture proximal tibia.

Above images are all original MR scans performed at Parkside MR Center.

Children and young adults frequently present with complaints of musculoskeletal pain. The usual etiology is often trauma but accurate diagnosis can be difficult in the absence of a history of acute injury. In children, owing to rapid bone growth, several types of injuries can occur.

Bone contusions or bone bruises are due to microfractures of the bony trabeculae. Plain film radiographs are often normal but MR imaging reveals areas of discrete edema and marrow hemorrhage. “Pediatric fracture without radiographic abnormality”¹ has been used to describe such injuries.

A “stress response” is typically an overuse injury and may have an appearance identical to a bone contusion. It occurs secondary to increased osteoclastic activity and can result in focal pain and swelling. If the affected limb is not rested, a stress fracture may ensue.

“Stress fractures” are characterized on MR images by a discrete line of trabecular disruption. They most commonly involve the tibia, ankle and foot. MR images are more sensitive than plain film radiographs in the diagnosis of stress fractures and helpful in the assessment of potential complications such as nonunion, soft tissue entrapment and growth plate involvement. MRI is also more specific than bone scanning.

References:
1. Beltran, J., Rosenberg, ZS: MR imaging of pediatric elbow fractures. Magn Reson Imaging Clin North Am5:567–568, 1997.

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