Skeletal surveys in young, injured children: A systematic review

Abstract

Skeletal surveys (SSs) have been identified as a key component of the evaluation for suspected abuse in young children, but variability in SS utilization has been reported. Thus, we aimed to describe the utilization patterns, yield, and risks of obtaining SS in young children through a systematic literature review. We searched PubMed/MEDLINE and CINAHL databases for articles published between 1990 and 2016 on SS. We calculated study-specific percentages of SS utilization and detection of occult fractures and examined the likelihoods that patient characteristics predict SS utilization and detection of occult fractures. Data from 32 articles represents 64,983 children <60months old. SS utilization was high (85%-100%) in studies of infants evaluated by a child protection team for suspected abuse and/or diagnosed with abuse except in one study of primarily non-pediatric hospitals. Greater variability in SS utilization was observed across studies that included all infants with specific injuries, such as femur fractures (0%-77%), significant head injury (51%-82%), and skull fractures (41%-86%). Minority children and children without private insurance were evaluated with SS more often than white children and children with private insurance despite lack of evidence to support this practice. Among children undergoing SS, occult fractures were frequently detected among infants with significant head injury (23%-34%) and long bone fractures (30%) but were less common in infants with skull fractures (1%-6%). These findings underscore the need for interventions to decrease disparities in SS utilization and standardize SS utilization in infants at high risk of having occult fractures.

Identifying Populations at Risk for Child Abuse: A Nationwide Analysis

“…The most common traumatic injuries identified on past admissions were orthopedic injuries, closed-head trauma, and burns. Additionally, having past traumatic injury was significantly associated with eventual hospitalizations for physical abuse, which indicates that a portion of the children with past abuse-related injuries [12,13,18,35] and subsequent hospitalization for abuse were likely cases of missed abuse. This failure of our healthcare system to detect abuse and attempt prevention of further abuse reveals an area for improvement in definitive identification and management of children with abuse.…”

“…Early identification of abuse is challenging, and physicians often miss the evidence of abuse that can lead to an appropriate intervention [1]. Successfully identifying abuse from particular injury patterns has been widely reported [11][12][13], yet despite this, abuse has been initially missed in 20%-30% of cases [12,14]. Consistent evidence has also shown that victims of child abuse have documented contact with the health care system, especially in the emergency department setting.…”

Medical diagnoses among infants at entry in out‐of‐home care: A Swedish population‐register study

“…1,8,11,30,31,33 Only specific diagnoses of abuse, or adverse social and parental circumstances preceding the date of first entry in the Out-of-home Care Register or within 15 days after that date, were categorized as exposure variables. Diagnoses of SDH, RH, rib fracture, or long bone fracture were selected that are claimed to have the highest positive predicative value for abuse, PPV of 0.69 for SDH, 9 0.97 for severe RH, 9 0.67 to 1.0 for rib fracture, 10,15,34 and 0.57 for long bone fracture. 11 Those diagnoses were combined in different categories and finally as one category, "SDH, RH, rib fracture, or long bone fracture" ( Table 1).…”

“…The following diagnoses, subdural haemorrhage (SDH), retinal haemorrhage (RH), skull fracture, rib fracture, classic metaphyseal lesions (CMLs), long bone shaft fracture, apnoea, and seizures, are claimed to be specific for the diagnosis of abuse . However, the scientific solidity of the SBS/AHT diagnosis has been questioned .…”

“…8 The following diagnoses, subdural haemorrhage (SDH), retinal haemorrhage (RH), skull fracture, rib fracture, classic metaphyseal lesions (CMLs), long bone shaft fracture, apnoea, and seizures, are claimed to be specific for the diagnosis of abuse. [9][10][11][12][13][14][15] However, the scientific solidity of the SBS/AHT diagnosis has been questioned. [16][17][18][19][20][21] A systematic literature review of the Swedish Agency for Health Technology Assessment and Assessment of Social Service (SBU) concluded that there is limited scientific evidence to explain the triad or its components (subdural haematoma, RHs, and encephalopathy) by isolated shaking.…”