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Three Part Question

In [children where there is a suspicion of non-accidental trauma] are [skeletal surveys] useful [in picking up occult fractures].

Clinical Scenario

A 6 month-old-female is brought to the emergency department by their parents after what they describe as a fall from a bed to the floor. The child has several bruises that appear to be in various stages of healing and the parents seem very tense. I suspect non-accidental injury. How likely am I to see occult fractures on a standard skeletal survey?

Search Strategy

Medline 1948-05/11 using OVID interface, Cochrane Library (2011), PubMed clinical queries
(exp child abuse/ OR abuse.mp OR NAI) AND (skeletal survey.mp/). Limit to English.

Search Outcome

65 papers were identified, three were relevant to the clinical question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Belfer et al, 2001, USA	Retrospectively reviewed the medical records of 203 children admitted over a 30-month period to Children's National Medical Center for alleged physical abuse. Skeletal surveys were ordered based on the treating physicians' clinical suspicions. Patients in whom skeletal surveys were positive for an occult fracture were studied in more detail.	Single center retrospective review	Of the 203 study patients, 96 (47%) had a skeletal survey.	71 of these 96 were negative (74%). 25 (26%) were positive for at least one clinically unsuspected fracture.	The study is retrospective and only invovled patients that were admitted to the hospital and not children that were evaluated and discharged. The sub-group of children that were admitted may have been more severely injured. Also, due to physician variability not all 203 children that were admitted got a skeletal survey.
Day et al, 2006, UK	All skeletal surveys performed at the Royal Hospital for Sick Children in Edinburgh for suspected non-accidental injury between 1/1/99 and 31/12/03 were reviewed.	Single institution retrospective review	Seventy-seven children underwent skeletal surveys for suspected non-accidental injury. 70 of these were index cases and 6 were siblings	Of the index cases, 17 (24%) skeletal surveys were positive, with a mean of 2.5 fractures per child. One of the six (17%) of the siblings’ surveys (a twin) was positive.	This study is retrospective and involves only a small number of surveys at this institution.
Duffy et al, 2011, USA	A retrospective, descriptive study of a consecutive sample of children who underwent a skeletal survey at a single children's hospital over 4 years.	Single institution retrospective analysis	703 skeletal surveys were performed for suspected abuse	Of the 703 skeletal surveys, 76 (10.8%) showed a fracture that was unsuspected or not recognized previously.	Retrospective study. Inability to account for physician bias in ordering study.

Comment(s)

Studies evaluating skeletal surveys (SSs) for non-accidental injury (NAI) in children have all been retrospective in design. One study (Belfer) looked only at SSs in children who were admitted to the hospital with a suspicion of NAI. The other two studies (Duffy and Day) included all SSs associated with NAI regardless of admission status. All studies are recent, retrospective, and from a single institution. All classified a positive study as one in which previously unsuspected fractures were identified. The range of positive SSs was from 11% to 26% in index patients. One study (Day) looked at siblings and noted 1/6 (17%) positive SSs. All studies found a high percentage of the positive surveys in children under 12 months of age and suggest that this study is particularly useful in the evaluation of this subset of children where there is suspicion of NAI.

Clinical Bottom Line

Skeletal surveys are useful in the evaluation of children when there is a suspicion of non-accidental injury. This investigation is particularly useful in the subset of children aged under 1 year of age.

References

1. Belfer RA, Klein BL, Orr L, et al. Use of the skeletal survey in the evaluation of child maltreatment American Journal of Emergency Medicine March 2001; 19(2): 122-4
2. Day F, Clegg S, McPhillips M, et al. A retrospective case series of skeletal surveys in children with suspected non-accidental injury Journal of Clinical Forensic Medicine Feb 2006; 13 (2) : 55-9
3. Duffy SO, Squires J, Fromkin JB, et al. Use of Skeletal Surveys to Evaluate for Physical Abuse: Analysis of 703 Consecutive Skeletal Surveys Pediatrics Jan 2011; 127 (1): e47-52