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RESEARCH ARTICLE Open Access
MR imaging for detection of trampoline
injuries in children
E. Hauth1*, H. Jaeger1, P. Luckey1 and M. Beer2
Abstract
Background: The recreational use of trampolines is an increasingly popular activity among children and
adolescents. Several studies reported about radiological findings in trampoline related injuries in children. The
following publication presents our experience with MRI for detection of trampoline injuries in children.
Methods: 20 children (mean 9.2 years, range: 4–15 years) who had undergone an MRI study for detection of
suspected trampoline injuries within one year were included. 9/20 (45%) children had a radiograph as the first
imaging modality in conjunction with primary care. In 11/20 (55%) children MR imaging was performed as the first
modality. MR imaging was performed on two 1.5 T scanners with 60 and 70 cm bore design respectively without
sedation. In 9/20 (45%) children the injury mechanism was a collision with another child. 7/20 (35%) children
experienced leg pain several hours to one day after using the trampoline without acute accident and 4/20 (20%)
children described a fall from the trampoline to the ground.
Results: All plain radiographs were performed in facilities outside the study centre and all were classified as having
no pathological findings. In contrast, MR imaging detected injuries in 15/20 (75%) children. Lower extremity injuries
were the most common findings, observed in 12/15 (80%) children. Amongst these, injuries of the ankle and foot
were diagnosed in 7/15 (47%) patients. Fractures of the proximal tibial metaphysis were observed in 3/15 children.
One child had developed a thoracic vertebral fracture. The two remaining children experienced injuries to the
sacrum and a soft tissue injury of the thumb respectively. Seven children described clinical symptoms without an
overt accident. Here, fractures of the proximal tibia were observed in 2 children, a hip joint effusion in another 2,
and an injury of the ankle and foot in 1 child. There were no associated spinal cord injuries, no fracture dislocations,
no vascular injuries and no head and neck injuries.
Conclusions: In the majority of children referred for MR imaging with pain after trampoline MR imaging detects
injuries. These injuries are often not visible on plain radiographs. Therefore we recommend a generous use of MR
imaging in these children after initial negative plain radiography.
Keywords: MR imaging, Trampoline, Injuries, Fracture
Background
The recreational use of trampolines continues to be a
popular activity among children and adolescents. An in-
creasing number of trampoline injuries were reported in
a published statement by the American Academy of
Orthopaedic Surgeons in 2010 [1]. In this statement the
Academy discouraged the use of trampolines in play-
grounds and advised to further study the use of
trampolines in supervised training and physical educa-
tion settings.
Most trampoline injuries are manifestations of muscu-
loskeletal injury mechanisms such as sprains, strains,
contusions and other soft tissue injuries whereas youn-
ger children seem to be more prone to undergo bone
injuries.
Several studies already described plain radiographic
findings in trampoline related injuries in children [2–7].
The upper extremities show fractures, such as supracon-
dylar humerus fractures or foream fractures due to
direct impact on the ground or the frame of the
* Correspondence: ehauth@t-online.de
1Radiologische Praxis, Parkstraße 10, 89073 Ulm, Germany
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hauth et al. BMC Pediatrics  (2017) 17:27 
DOI 10.1186/s12887-017-0791-2
trampoline. The lower extremities have a higher inci-
dence of injuries. Axial forces to the ankle and knee
joints explain growth arrest lines, widening of the
growth plates, sclerosis of the metaphysis or Salter-
Harris type fractures of the distal femur [5]. Fractures of
the proximal tibia were the most common described
injury [2–5].
The following publication presents our experience
with MR imaging for detection of trampoline injuries in
children.
Methods
In 2014, we identified 20 children in whom MR imaging
was performed for suspected trampoline injuries. The
indication for MR imaging was done by the referring
physician. Twelve girls and 8 boys with an age range
from 4 to 15 years (mean 9.2 years) were examined. Five
of these were six years or less of age. All injuries had oc-
curred in the summer months from April to September
2014.
In 9/20 (45%) children the cause of injury was a
collision with another child. 7/20 (35%) children de-
veloped leg pain several hours to one day after using
the trampoline without overt accident and 4/20 (20%)
children described a fall from the trampoline to the
ground.
11/20 (55%) children had used a trampoline without
a net and 9/20 (45%) children a net-secured device.
Plain radiographs in two views were performed in
institutions outside the study centre in 9/20 (45%)
children. All radiographs were classified as normal
without fracture signs. In 11/20 (55%) children MR
imaging was the first imaging modality. MR imaging
was performed after informed consent was obtained
from the parents.
MR imaging was performed on a 1.5 T scanner
(Magnetom Aera®; Siemens, Erlangen, Germany) with a
70 cm open bore design and a system length of 145 cm
and on a 1.5 T scanner (Magnetom Symphony®, Siemens,
Erlangen, Germany) with a bore diameter of 60 cm and
a system length of 160 cm.
MR imaging of the thoracic and lumbar spine included
a sagittal and coronal T2-weighted turbo inversion re-
covery magnitude (TIRM)- sequence for diagnosis of
bone marrow oedema, sagittal T2-weighted turbo spin
echo (TSE) and T1-weighted TSE-sequences for optimal
diagnosis of fracture lines and vertebral endplate depres-
sion as well as a transverse T2-weighted TSE-sequence
for optimal imaging of the spinal canal.
For MR imaging of the knee, ankle/foot and thumb we
utilized proton (PD)-weighted sequences in coronal, sa-
gittal and transverse planes for diagnosis of bone mar-
row oedema and a sagittal T1-weighted (TSE) sequence
for optimal detection of fracture lines.
No intravenous contrast was administered and no sed-
ation was performed. In 8/20 (40%) children a parent
stayed in the scanner room during the acquisition to
watch and if necessary talk to the child. The mean scan
time was 15.7 min (Range: 10–32 min). No other
Table 1 Spectrum of injuries in MR imaging of 15 children
sorted according to anatomic regions
Case Region of injury Anatomical injuries
Nr.15 (Figs. 1 and 2) thoracic spine fracture T6 vertebral
Nr. 6 lumbar spine marrow oedema of sacrum
Nr. 5,12 hip joint effusion
Nr.10,16,19 (Fig. 3) knee fracture of proximal tibia
Nr.1 ankle joint/foot marrow oedema of distal
tibia and talus,
fracture of cuboid
Nr.3 ankle joint/foot fracture of talus, cuboid,
ligament rupture
Nr.2,7 ankle joint/foot ligament rupture
Nr.13 (Figs. 4, 5 and 6) ankle joint/foot marrow oedema of talus,
cuboid, metatarsals III,IV
Nr.14 ankle joint/foot fracture of talus, cuboid,
navicular, calcaneus
Nr. 4 (Figs. 7 and 8) ankle joint/foot marrow oedema of navicular,
fracture of first metatarsal
Nr.8 thumb soft tissue injury
Note: In 5/20 (25%) children no injuries were observed
Fig. 1 Close up sagittal STIR MR imaging shows oedema and slight
impression of the upper endplate of T6 vertebral (arrow)
Hauth et al. BMC Pediatrics  (2017) 17:27 Page 2 of 6
imaging modality was employed after the MRI scan was
obtained.
Results
MR imaging of the following regions was performed:
Thoracic spine in 4/20 (20%), lumbar spine in 3/20
(15%), hip in 2/20 (10%), knee in 3/20 (15%), ankle and
foot in 7/20 (35%) and thumb in 1/20 (5%) children.
In 15/20 (75%) children MR imaging detected injuries,
in 5/20 (25%) children imaging was normal. Table 1 de-
picts the spectrum of diagnosed injuries in 15 children
sorted by anatomic regions.
In 1/15 children a thoracic vertebral fracture was diag-
nosed (Figs. 1 and 2). Lower extremity injuries were ob-
served in 12/15 (80%) children. Out of these fractures
the proximal tibial metaphysis was diagnosed in 3 chil-
dren (Fig. 3) and injuries of the ankle and foot were di-
agnosed in 7/15 (47%) patients (Figs. 4, 5, 6, 7 and 8).
In regards to 7 symptomatic children without overt ac-
cident we observed fractures of the proximal tibia in 2/7,
hip joint effusion in 2/7 and an ankle/foot injury in 1/7
children. The 2/7 remaining children did not present
any injuries in MR imaging.
Overall there were no associated spinal cord injuries,
no fracture dislocations, no vascular injuries and no
head and neck injuries and no surgical management was
necessary.
Discussion
Our retrospective analysis of children examined for
complaints related to trampoline use demonstrates posi-
tive findings in the majority of scanned children 15/20
(75%) with lower extremity injuries being the predomin-
ant type with 12/15 (80%) patients. Our results compare
well with some studies where described trampoline
injuries most frequently involved the lower extremity
[8, 9]. Other studies revealed a preponderance of
upper extremity injuries [5, 6, 10]. Klimek et al. [5]
for example described as the most common injuries
upper extremity fractures such as supracondylar humeral
Fig. 2 Shows the impression of the upper endplate of T6 vertebral
in close up sagittal T1-weighted TSE MR imaging (arrow)
Fig. 3 Girl with pain on the tibia after jumping on the trampoline.
Coronal STIR sequence shows a fracture (arrow) of the proximal tibia
metaphysis with surrounding soft tissue damage
Hauth et al. BMC Pediatrics  (2017) 17:27 Page 3 of 6
and forearm fractures, which were frequently caused by a
direct impact on the ground.
We diagnosed injuries of the ankle and foot in 7/15
(47%) children. In a study performed by Shankar et al.
[8] more than 60% of lower extremity injuries involved
the ankle and approximately three-quarters of ankle in-
juries were sprains.
In two studies [2, 4] the trampoline-related fracture of
the proximal tibia is the most frequently described tram-
poline injury. This so called “trampoline fracture” is
often observed in children younger than 6 years [2]. We
diagnosed this type of fracture in 3/15 children. Due to
age-related weakness the proximal tibia is especially vul-
nerable to axial forces and depression fractures. The in-
jury mechanism was explained in detail by Boyer et al.
[2]. According to him, trampoline fractures often occur,
when children are using a trampoline with another heav-
ier person. When this person jumps up the trampoline
Fig. 4 Sagittal PD fat saturated sequence shows marrow oedema of
talus (arrow) without fracture signs in T1-weighted sequence
in Fig. 5
Fig. 5 Sagittal T1-weighted sequence did´nt showed a fracture
Fig. 6 Axial STIR sequence shows marrow oedema of cuboid (arrow)
and base of metatarsal IV (arrow ahead)
Hauth et al. BMC Pediatrics  (2017) 17:27 Page 4 of 6
mat recoils upwards from its stretched downward pos-
ition. If the smaller child lands on the upwards moving
mat at the time when its elasticity is reversed by recoil
and the springs are shortening to their original length, a
significant upward impaction force is applied to the
lower extremity of the child. This force may be sufficient
to cause fracture. We therefore discourage the trampo-
line use for children younger than six years of age,
especially in regards to jumping simultaneously with
older children or adults. The International Trampoline
Industry Association and the American Society of
Testing and Materials Trampoline Subcommittee issued
a revision of performance and safety standards. In this
paper printed warnings were included with new trampo-
line equipment that recommend avoiding somersaulting,
restricting multiple jumpers and limiting trampoline use
to children 6 years or older [1].
Fractures of the proximal tibial metaphysis may ini-
tially appear very subtle on plain radiographs. Therefore
in a study of Klimek et al. [5] repeat radiographs after
7–10 days are recommended in children with persistent
complaints as an alternative to MRI. Stranzinger et al.
[4] described buckle/torus or transverse hairline frac-
tures of the proximal tibial metaphysis as the most com-
mon manifestations of the “trampoline fracture”. In their
Fig. 7 Axial STIR MR imaging shows marrow oedema of navicular
(arrow ahead) and metatarsal I (arrow)
Fig. 8 Axial T1-weighted TSE imaging shows a fracture (arrow) on
the base of the first metatarsal
Hauth et al. BMC Pediatrics  (2017) 17:27 Page 5 of 6
study children with trampoline fractures showed signifi-
cantly higher anterior tilt angles of the proximal tibial
epiphyseal plate on lateral radiographs compared to a
control group. They concluded that abnormal anterior
tilt angles support the diagnosis of a “trampoline
fracture”. They performed follow-up radiographs to ex-
clude valgus deformities and early growth plate closure
in their patients. In our study fractures of proximal tibial
metaphysis were diagnosed by MRI only, all prior radio-
graphs had been classified as normal.
Our study has some limitations though. Plain X-Rays
had been performed at outside, non-pediatric institu-
tions with potential considerable differences in diagnosis.
Measurement of the anterior tilt angle was not included
in the radiographic analysis. The radiographs were not
re-reviewed by pediatric or dedicated musculoskeletal
specialists. Another limitation is that our results were
not compared with findings in children examined only
with radiography, CT or ultrasound. To reduce radiog-
raphy utilization musculoskeletal sonographic evaluation
can be useful to find soft tissue swelling, adjacent and
subperiostal hematomas and bone fragments or distal
humeral epiphyseal separation [11, 12].
Another limitation of this study is a potential sampling
bias. The authors have only knowledge of the children,
who were referred for MR imaging. Therefore no broad
conclusions regarding the general nature of trampoline-
related injuries can be made.
Conclusions
In the majority of children referred for MR imaging
with pain after trampoline MR imaging detects injur-
ies. These injuries are often not visible on plain ra-
diographs. Therefore we recommend a generous use
of MR imaging in these children after initial negative
plain radiography.
Abbreviations
MRI: Magnetic resonance imaging; PD: Proton weighted; STIR: Short tau
inversion recovery; TSE: Turbo-spin-echo
Acknowledgments
The authors have no acknowledgements.
Funding
In the study no funding was received.
Availability of data and materials
All data supporting our findings are contained within the manuscript.
Authors’ contributions
The study was designed by EH, HJ, MB. The data were collected and
analyzed by EH, HJ and MB. The first draft of the paper was written by EH
and all authors provided critical revisions of intellectual content. The
manuscript was corrected by a native English speaker (PL). All authors have
read and approved the final manuscript.
Authors’ information
The last author MB is director of the department of Diagnostic and
Interventional Radiology of the University Hospital Ulm and a pediatric
radiologist.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
“Not applicable”.
Ethics approval and consent to participate
Currently, ethical approval for retrospective and non-interventional studies is
not necessary in German institutions. Therefore ethical approval was not
obtained. A national guideline is planned, but not yet available. We
followed the local guidelines from the University of Luebeck (https://
www.uni-luebeck.de/forschung/kommissionen/ethikkommission/fragen-
und-antworten.htm) and from the professional medical body of the
region Nordrhein (Ärztekammer Nordhrein) (https://www.aekno.de/
page.asp?pageID=57#_15).
Written informed consent was obtained from the parents for MR imaging.
Author details
1Radiologische Praxis, Parkstraße 10, 89073 Ulm, Germany. 2Department of
Diagnostic and Interventional Radiology, University Hospital, Ulm, Germany.
Received: 29 August 2016 Accepted: 11 January 2017
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