**13.2.6 Fractures**

The occult fracture more common in children is the Toddler's fracture, which is a spiral or oblique fracture that can occur from pelvis to feet but mostly involves the tibia (Shammas, 2009). Radiographic findings are often subtle and fractures may not be apparent, for that reason bone scan is a valuable tool for detecting this injury. Scintigraphy shows diffuse increased uptake in the tibial diaphysis or the bone affected. A linear or spiral pattern of high uptake may be seen in some children (Shammas, 2009; as cited in Connolly et al., 2006; Gilday 2003).

Among stress fractures, spondylolysis is the more important in children with back pain, which represent a stress fracture of the pars interarticularis of the vertebra, commonly in the lower lumbar spine secondary to repetitive minor trauma such as hyperextension (Shammas, 2009). Clinical signs and symptons and radiographies are normally used for the diagnosis. A bone scan or a MRI may be necessary to determine if the spondylolysis is active or inactive. Bone scintigraphy shows little or no abnormality on blood pool images, but it typically demonstrates focally high uptake in the region of the pars interarticularis on delayed images. SPECT imaging is more sensitive than planar studies and detects abnormalities in about a third of individuals with normal planar examinations and so, it is recommended in the evaluation of low back pain in young athletes (Shammas, 2009; as cited in Sty, 1993).

Scintigraphy has also an important role to provide a quick assessment for defining and characterizing the extent and severity of trauma in the setting of child abuse, complementary to other radiologic investigations. Its major advantage is the increased sensitivity in detecting evidence of soft-tissue and bone trauma (25%to 50%), and in the documentation of specific and characteristic sites of abuse, such as in the ribs or the diaphyses of the extremities (Nadel & Stilwell, 2001; as cited in Conway et al., 1993, Sty & Wells, 1994).
