Original Contributions
Use of the skeletal survey in the evaluation of child maltreatment*

https://doi.org/10.1053/ajem.2001.21345Get rights and content

Abstract

The radiologic skeletal survey is an important tool for evaluating occult trauma in suspected child abuse. The purposes of this study were: (1) to determine the incidence of clinically unsuspected fractures detected by skeletal survey, and (2) to identify high-risk groups of children who would benefit from skeletal surveys. We 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. There were 96 skeletal surveys performed; of these, 25 were positive for at least 1 clinically unsuspected fracture. Eighty percent of occult fractures were found in children younger than 1 year old. Presenting with a new fracture or an intracranial injury placed the child at higher risk of occult fracture. In contrast, patients with burn injuries had a very low yield of occult fractures. The patient's age and type of suspicious injury can help guide the physician as to when to obtain a skeletal survey. (Am J Emerg Med 2001;19:122-124. Copyright © 2001 by W.B. Saunders Company)

Section snippets

Methods

This study was conducted at Children's National Medical Center (CNMC), a large, urban, tertiary care, teaching hospital in Washington, DC. A retrospective analysis of the medical records of all children admitted to CNMC over a 30-month period with a diagnosis of alleged physical abuse was performed. All patients were evaluated by the multidisciplinary Division of Child Protection team.

For each child, data compiled included primary and secondary admitting diagnoses and the results of medical and

Results

The initial study group consisted of 203 admitted patients. The median age of the patients was 14 months, with a range of 2 weeks to 16 years old. Of these patients 67% were younger than 24 months of age. Thirty-five patients, 6 of whom had negative skeletal surveys performed, were older than 48 month of age.

Diagnosis

Primary and secondary admission diagnoses included burns (n = 75), new fractures (N = 61), intracranial injuries (N = 49), and bruises (N = 34). Some patients had more than one diagnosis (Table 2).

. Admission Diagnosis

DiagnosisNo.
Burn Injury75
New fracture61
 Skull27
 Femur24
 Humerus4
 Hand2
 Radius2
 Tibia1
 Clavicle1
Intracranial Injury49
 Subdural/subarachnoid hematoma32
 Closed head injury16
 Intracranial hemorrhage1
Skin bruises34

Of the 203 study patients, 96 (47%) had skeletal surveys performed. Skeletal surveys

Age relationship

Skeletal surveys were performed more often in younger patients; 78/135 (58%) of patients younger than 2 years of age had skeletal surveys, whereas 18/68 (26%) older than 2 years had skeletal surveys (P <.05).

The radiologic yield of the skeletal survey (number of patients with fractures/number of studies) was significantly greater in younger patients. Of the 78 patients younger than 24 months of age who had surveys performed, 24 surveys (31%) yielded evidence of occult fractures. Only 1 of the

Types of injuries

In patients with evidence of an occult fracture detected by skeletal survey, 60% (15/25) were seen in the emergency department (ED) for a new fracture, and 24% (6/25) for an intracranial injury. Only 1 patient with a clinically unsuspected fracture had a burn injury (a 10-month old).

Sixty-one patients presented to the ED with new fractures; 48 skeletal surveys (79%) were done, and 15 (31%) showed evidence of at least 1 occult fracture. Forty-nine patients presented to the ED with an

Location of occult fractures

The 25 positive skeletal surveys revealed a total of 77 occult fractures. Fifteen patients had multiple old fractures identified by skeletal survey. Foci of skeletal trauma were scattered throughout the skeleton. Ribs were the most frequent site of old injury; a total of 33 ribs had radiographic evidence of fracture. Multiple rib fractures occurred in 9 patients (Table 3).

. Location and Number of Occult Fractures in the 25 Patients With Positive Skeletal Surveys

Rib          33          
Femur10
Tibia8
Radius6
Ulna6

Discussion

In 1946, Caffey described 6 infants with subdural hematomas who had 23 long bone fractures. In none was there a history of injury to which the skeletal lesions could be attributed. He advocated the use of routine radiologic studies to detect such clinically silent fractures.3 Along these lines, the landmark article by Kempe et al on battered child syndrome recommended using skeletal surveys to detect unrecognized trauma in this population of abused children. They stressed that radiologic

Conclusion

The skeletal survey is an important radiologic tool for the clinical evaluation of patients with suspected child abuse. Our results support the American Academy of Pediatrics' recommendations for obtaining this test, and we agree that skeletal surveys should be performed on all physically abused children younger than 2 years of age. Regarding specific injury types, children with new fractures or intracranial injuries are at high risk for occult fractures. Patients with burn injuries as their

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    Multiple fractures in the long bones of infants suffering from chronic subdural hematoma

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There are more references available in the full text version of this article.

Cited by (88)

  • Skeletal surveys in young, injured children: A systematic review

    2018, Child Abuse and Neglect
    Citation Excerpt :

    Among siblings of abused children evaluated by a CPT, 5% had occult fractures (Lindberg et al., 2012). For studies that included all injuries and presentations in children age ≥ 24 months, 6%-18% of those with suspected abuse and 8% of those diagnosed with abuse had occult fractures (see Fig. 3; Barber et al., 2013; Belfer et al., 2001; Day et al., 2006; Duffy et al., 2011; Lindberg et al., 2014). Among children ≥ 24 months old with severe head injury, an abusive fracture evaluated by a CPT, or abusive burns, 19% (Hymel et al., 2015), 44% (Ravichandiran et al., 2010), and 29% (Fagen et al., 2015), respectively, had occult fractures.

  • Skeletal Manifestations of Child Maltreatment

    2016, Clinical Pediatric Emergency Medicine
  • Follow-up skeletal survey use by child abuse pediatricians

    2016, Child Abuse and Neglect
    Citation Excerpt :

    The radiographic skeletal survey (SS) is widely used to improve recognition of abuse by identifying additional occult fractures (Kleinman et al., 2009). In several cohorts of children with concerns for abuse, the SS has been shown to identify additional fractures in 10–34% of cases in which it is obtained (Barber, Perez-Rossello, Wilson, & Kleinman, 2014; Belfer, Klein, & Orr, 2001; Duffy, Squires, Fromkin, & Berger, 2011; Karmazyn, Lewis, Jennings, Hibbard, & Hicks, 2011; Lindberg et al., 2014; Merten, Radkowski, & Leonidas, 1983). For this reason, SS is considered “mandatory” by the American Academy of Pediatrics (AAP) for any child less than two years old with concern for physical abuse (Christian & Committee On Child, & Neglect, 2015; Kleinman et al., 2009).

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*

Address Reprint requests to Bruce L. Klein, MD, Division of Emergency Medicine, Children's National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010. [email protected]

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