Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed?

Harlan, Susan R.; Nixon, George W.; Campbell, Kristine A.; Hansen, Karen; Prince, Jeffrey S.

doi:10.1007/s00247-009-1313-7

Cited by 57 publications

(43 citation statements)

References 11 publications

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“…116 The number of images on the follow-up examination may be limited to 15 views by omitting the views of the skull, pelvis, and lateral spine. 118 Radiography may assist in assessing the approximate time when an injury occurred because long bone fractures heal following a particular sequence. 119 If the healing pattern is not consistent with the explanation provided, the accuracy of the explanation should be questioned.…”

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confidence: 99%

Evaluating Children With Fractures for Child Physical Abuse

Peréz-Rosselló¹,

Levine²,

Hennrikus³

et al. 2014

Pediatrics

247

162

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Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Pediatrics 2014;133:e477-e489 INTRODUCTIONFractures are the second most common injury caused by child physical abuse; bruises are the most common injury. 1 Failure to identify an injury caused by child abuse and to intervene appropriately may place a child at risk for further abuse, with potentially permanent consequences for the child. 2-4 Physical abuse may not be considered in the physician' s differential diagnosis of childhood injury because the caregiver may have intentionally altered the history to conceal the abuse. 5 As a result, when fractures are initially evaluated, a diagnosis of child abuse may be missed. 3 In children younger than 3 years, as many as 20% of fractures caused by abuse may be misdiagnosed initially as noninflicted or as attributable to other causes. 3 In addition, fractures may be missed because radiography is performed before changes are obvious or the radiographic images are misread or misinterpreted. 2 However, incorrectly diagnosing physical abuse in a child with noninflicted fractures has serious consequences for the child and family. To identify child abuse as the cause of fractures, the physician must take into consideration the history, the age of the child, the location and type of fracture, the mechanism that causes the particular type of fracture, and the presence of other injuries while also considering other possible causes. DIFFERENTIAL DIAGNOSIS OF FRACTURES Trauma: Child Abuse Versus Noninflicted InjuriesFractures are a common childhood injury and account for between 8% and 12% of all pediatric injuries. [6][7][8] In infants and toddlers, physical FROM THE AMERICAN ACADEMY OF PEDIATRICSGuidance for the Clinician in Rendering Pediatric Care by guest on May 11, 2018 http://pediatrics.aappublications.org/ Downloaded from abuse is the cause of 12% to 20% of fractures. 9 Although unintentional fractures are much more common than fractures caused by child abuse, the physician needs to remain aware of the possibility of inflicted injury. Although some fracture types are highly suggestive of physical abuse, no pattern can exclude child abuse. 10,11 Specifically, it is important to recognize that any fracture, even fractures that are commonly noninflicted injuries, can be caused by child abuse. Certain details that can help the physician determine whether a fracture was caused by abuse rather than unintentional injury include the hist...

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confidence: 99%

Evaluating Children With Fractures for Child Physical Abuse

Peréz-Rosselló¹,

Levine²,

Hennrikus³

et al. 2014

Pediatrics

247

162

View full text Add to dashboard Cite

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“…The total study population included 97 cases from the 2009 study. 6 The data from that study were recollected based on the present study' s protocol.…”

Section: Methodsmentioning

confidence: 99%

“…[4][5][6][7][8][9] When SS2 has a positive yield, the new information affects the abuse-related diagnosis by increasing certainty, decreasing certainty, or reversing the diagnosis in 14% to 41% of cases. [5][6][7][8] These features make SS2 important in the accurate medical evaluation and diagnosis of abuse. They also make SS2 important in the complete documentation of all injuries when the diagnosis of abuse has been made.…”

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confidence: 99%

“…12 In 2009, our center published a study that suggested that the spine and pelvis views could be omitted from SS2 without loss of information when no spine or pelvis findings (fractures or questioned fractures) were present on SS1. 6 Removing routine spine and pelvis views from SS2 not only eliminates the highest single radiation dose views from the study but also decreases radiation to the thymus, thyroid, and gonads, which are particularly sensitive to radiation. This is in keeping with the ALARA concept while maintaining the goals of accurate diagnosis and complete documentation of injuries.…”

mentioning

confidence: 99%

“…6 Our hypothesis was that there would be no clinically significant difference in results from a limited view SS2 protocol that omits the spine and pelvis views (when no spine or pelvis fractures or questioned fractures are present on SS1) compared with a traditional SS2 protocol for radiographic evaluation of suspected physical abuse.…”

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Sensitivity of the Limited View Follow-up Skeletal Survey

et al. 2014

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BACKGROUND AND OBJECTIVE: Reducing radiation exposure to minimize risk has been emphasized in recent years. In child abuse, the risk of missing occult injuries is often believed to outweigh radiation risk associated with skeletal surveys. Our hypothesis was that there would be no clinically significant difference in results from a limited view, follow-up skeletal survey (SS2) protocol, which omits spine and pelvis views unless these views have findings on the initial skeletal survey (SS1), compared with a traditional SS2 protocol for radiographic evaluation of suspected physical abuse. METHODS: This study was a retrospective record review involving 5 child protection teams. Consultations for suspected physical abuse were reviewed to identify subjects <24 months of age who had an SS1 and a traditional SS2. The results of these studies were compared to identify subjects in which newly identified spine and pelvis fractures (fractures seen only on SS2 and not on SS1) would have been missed by using a limited view SS2 protocol. RESULTS: We identified 534 study subjects. Five subjects had newly identified spine fractures, and no subjects had newly identified pelvis fractures on traditional SS2 studies. Only 1 subject with a newly identified spine fracture would have been missed with the limited view SS2 protocol used in this study (0.2% [95% confidence interval: <0.005–1.0]). None of the newly identified fractures changed the abuse-related diagnosis. CONCLUSIONS: We found no clinically significant difference in the results of a limited view SS2 protocol versus a traditional SS2 protocol for radiographic evaluation of suspected abuse.

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What does the recent literature add to the identification and investigation of fractures in child abuse: an overview of review updates 2005–2013

Maguire¹,

Cowley²,

Mann³

et al. 2013

Evid.‐Based Child Health

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Background:Fractures are a manifestation of physical abuse and common accidental injuries. Distinguishing which fractures are indicative of abuse and optimizing the identification of occult fractures are the challenges.Objectives:To identify additional studies published since our original systematic reviews to address these two issues.Methods:An all‐language literature search of 14 databases was conducted for the years 2005–2013, using revised keywords. All studies underwent standardized critical appraisal by two independent reviewers, applying quality criteria relating to the confirmation of child abuse, exclusion of abuse and quality of skeletal survey conducted. A meta‐analysis, stratified by age, was conducted to determine the predictive value for abuse of specific fractures by fitting a random effects model.Results:Twenty‐three studies addressed ‘radiological investigations’, and nine studies ‘fractures indicative of abuse’. Radiological studies reiterated that a single investigation (skeletal survey or radionuclide imaging ) will miss some abusive fractures; in 8.4–37.6% of children, the repeat skeletal survey added new information that influenced the child protection procedures. Debate continues as to the optimal images to include in the repeat skeletal survey. A meta‐analysis of femoral and humeral fractures by age highlighted that children younger than 18 months are significantly more likely to have sustained their fracture as a consequence of abuse, than those aged 1–4 years.Authors' Conclusions:Recent literature validates the original conclusions that repeat skeletal imaging adds important information on fractures. Comparative studies of femoral, humeral, rib and skull fractures enabled a meta‐analysis by age, however further comparative studies are needed.

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Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed?

Abstract: Our data demonstrate that a 15-view limited follow-up skeletal survey could be performed without missing clinically significant new fractures and still allow proper identification of confirmed fractures or normal findings. A limited survey would decrease radiation dose in children.

Cited by 57 publications

References 11 publications

Evaluating Children With Fractures for Child Physical Abuse

Evaluating Children With Fractures for Child Physical Abuse

Sensitivity of the Limited View Follow-up Skeletal Survey

What does the recent literature add to the identification and investigation of fractures in child abuse: an overview of review updates 2005–2013

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