Elsevier

Clinical Radiology

Volume 61, Issue 9, September 2006, Pages 723-736
Clinical Radiology

Review
Which radiological investigations should be performed to identify fractures in suspected child abuse?

https://doi.org/10.1016/j.crad.2006.03.017Get rights and content

Aims

To determine which radiological investigations should be performed and which children should be investigated.

Materials and methods

An all language literature search of original articles; from 1950-October 2005. Two reviewers independently reviewed each article. A third was carried out on disagreement. Each study was assessed using standardised data extraction, critical appraisal and evidence forms.

Results

Thirty-four studies were included. Fifteen addressed the question: which investigation has a higher yield, skeletal surveys (SS) or bone scintigraphy (BS)? Studies gave conflicting results. Overall neither investigation is as good as the two combined. BS predominately missed skull, metaphyseal and epiphyseal fractures, whereas SS commonly missed rib fractures. Two studies showed that a repeat SS 2 weeks after the initial study provided significant additional information about tentative findings, the number and age of fractures. A comparative study evaluated additional oblique views of ribs in 73 children and showed improved diagnostic sensitivity, specificity and accuracy. Four studies addressed the diagnostic yield for occult fractures with respect to age. This was significant for children under 2-years old.

Conclusions

In children under 2-years old, where physical abuse is suspected, diagnostic imaging of the skeleton should be mandatory. SS or BS alone is inadequate to identify all fractures. It is recommended that all SS should include oblique views of the ribs. This review suggests that the following options would optimize the diagnostic yield. However, each needs to be evaluated prospectively: SS that includes oblique views, SS and BS, a SS with repeat SS or selected images 2 weeks later or a BS plus skull radiography and coned views of metaphyses and epiphyses.

Introduction

Non-accidental fractures in children denote severe assault and must be identified if present. Fractures have been recorded in up to 55% of young children who have been physically abused.1, 2 Most of this group are under 3 years of age, with 80% less than 18 months old.3 Abusive fractures are often occult in these young children, who are unable to give a history, and where symptoms and signs can be difficult to interpret.4, 5, 6 The investigating paediatrician must have access to sensitive radiological techniques to identify these fractures, which are frequently multiple,3, 7 widely distributed throughout the skeleton and may show different stages of healing.8 Both acute rib fractures4 and metaphyseal fractures are associated with abuse, but are easily missed on radiographs.9

The first reference to unexplained fractures in association with subdural haemorrhage in infants was by Caffey10 in 1946. Since that time clinicians have attempted to exclude fractures in infants where physical abuse is suspected. The standard investigation has evolved from the simple baby-gram to skeletal surveys (SS) in their current recommended form (Table 1).11, 12 In the early 1980s publications suggested that bone scintigraphy (BS) was an appropriate investigation.13, 14, 15 Currently both investigations are used to delineate the pattern and extent of fractures in the diagnosis and management of child abuse. Radiology findings may be used as medical evidence in court and they can have a significant bearing on the legal outcome in either civil or criminal proceedings.16

The British Society of Paediatric Radiologists (BSPR) and the American College of Radiology (ACR) have produced guidelines for the radiological investigation of suspected abuse, detailing imaging techniques, qualifications of relevant specialists and views to be taken.11, 12 Neither addresses the role of BS. Although both recommend that SS should be performed in infants and young children where physical abuse is suspected, neither defines which age group should be investigated. We have conducted a systematic review to determine the optimal radiological investigations that should be performed to detect fractures in suspected physical abuse and which children should be investigated.

Section snippets

Search criteria

We performed an all-language literature search using the keywords listed in Table 2 of original articles from 1950–October 2005 (Fig. 1). Literature before this date was appropriately hand-searched from 1947 onwards.

Inclusion criteria

We included studies of live children less than 18-years old who had radiological investigations to identify bone fractures in suspected child abuse. The following were excluded: review articles, consensus statements or expert opinion, studies where details on children could not be

Results

Fig. 1 summarizes all of the studies scanned and reviewed; 34 studies were included. The methodological techniques for investigations differed between studies and the rationale for choosing investigations were not stated, age ranges of included cases varied.

Discussion

These studies confirm that the diagnostic rate for occult fractures in young children is significant and that a sensitive radiology investigation strategy is fully justified. Delineation of the full extent of fractures sustained by an abused child is important to inform the degree of certainty of abuse, the extent, severity and chronicity of the physical abuse, and assist in assessing the possible mechanisms of injury.

All children under the age of 2 years, where physical abuse is suspected,

Acknowledgements

The authors thank the NSPCC for their financial support of this systematic review, and all of our reviewers.

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