Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal

Bennett, Berkeley L.; Chua, Michael S.; Caré, Marguerite M.; Kachelmeyer, Andrea; Mahabee-Gittens, Melinda

doi:10.1186/1756-0500-4-354

Cited by 48 publications

(32 citation statements)

References 7 publications

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“…109,116 The follow-up examination may identify fractures not seen on the initial skeletal survey, can clarify uncertain findings identified by the initial skeletal survey, and improves both sensitivity and specificity of the skeletal survey. 116,117 In one study, 13 of 19 fractures found on the follow-up examination were not seen on the initial series. 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.…”

Section: Imaging Approachmentioning

confidence: 99%

Evaluating Children With Fractures for Child Physical Abuse

Peréz-Rosselló¹,

Levine²,

Hennrikus³

et al. 2014

Pediatrics

238

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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Section: Imaging Approachmentioning

confidence: 99%

Evaluating Children With Fractures for Child Physical Abuse

Peréz-Rosselló¹,

Levine²,

Hennrikus³

et al. 2014

Pediatrics

238

162

View full text Add to dashboard Cite

show abstract

“…[4][5][6][7][8][9]29 Although of different design, and occurring in different time periods (some involving screen-film and others computed or digital radiography), all have supported the utility of SS2 in the evaluation of child abuse. Our study also demonstrates this utility, and our yield of 38.8% is comparable to the yield demonstrated in previous studies (14%-61%).…”

Section: Discussionmentioning

confidence: 99%

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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“…Some studies have found that all children with normal initial surveys have normal follow-up surveys14 while others such as Bennett et al 16 found otherwise. They analysed the follow-up skeletal surveys of 47 children who had normal initial skeletal surveys and found signs of healing bone trauma in 8.5% (4/47); three children had healing rib fractures and one had a proximal humeral fracture.…”

Section: Follow-up Skeletal Surveysmentioning

confidence: 99%

Imaging in suspected child abuse: necessity or radiation hazard?

Bajaj¹,

Offiah

2015

Arch Dis Child

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Imaging has many uses, but in cases of suspected child abuse, radiographs and CT scans are vital in identifying fractures and head injury that may not be clinically obvious. There are growing concerns about the small but potential adverse effects of radiation, including cancer, in the paediatric population as a result of imaging. The vast majority of general paediatricians undertaking child abuse assessments request skeletal surveys and CT scans, subjecting children to significant amounts of radiation. Informed consent must be taken from parents for these procedures and therefore this paper aims to look at evidence of the dangers of radiation in children and raise awareness among paediatricians.

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Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal

Cited by 48 publications

References 7 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

Imaging in suspected child abuse: necessity or radiation hazard?

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