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The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.


  • Of 540 studies reviewed, twelve studies addressed the issue 1-12
  • Study design:
    • 3 longitudinal studies 8,9,12
    • 6 case study / case series 1,2,4,7,10,11
    • 3 cross sectional 3,5,6
  • Gender: data not analysed by gender
  • Age range:
    • 0 – 41 months, one study included children up to ten years 4
  • These studies did not address radiological investigations of disabled children
  • Influence of ethnicity and socio-economic group: not addressed by these included studies


Details of included studies


Author, year, study design

Number of children undergoing repeat imaging / total children

Imaging performed

Time interval



Harper et al, 2013 5

Cross sectional

796/1038 (76.7%)

20 centres included full SS according to AAP guidance 2009. At follow-up all centres excluded skull, 6 centres excluded spine, five excluded pelvis

Not available

124/796 (15.6%) had a new fracture, fractures included rib, long bone, CML, hands or feet, clavicle, vertebra and scapula. 18/252 (7.1%) of children with a normal initial SS had fractures on follow-up. Concerning features were confirmed as normal in 55 subjects

Prospective study across 20 centres. Indications not given. 6.5% of subjects had fractures of hands and feet on follow-up and 1.6% vertebral fractures. No new fractures of the pelvis were identified. 24% of subjects did not return for follow-up imaging

Singh et al, 2012 9

Retrospective cohort


Full SS including oblique views initially, omitted skull and spine for follow up imaging

Mean 19+/- 11 days

24/169 (14%) had previously unrecognized healing fractures on follow up

6/24 (25%) of these subjects had a negative initial SS

Retrospective review from 2002-2009, 88% < 1 year. Significant increase in number of follow up SS 2005-2009. 24/169 fractures identified on follow up SS. 2 fractures missed on initial SS. In 8 cases findings on follow up influenced abuse diagnosis, 6 negative initial SS. Only 11% of initial cohort underwent repeat imaging. Noted new, and newly recognized, metacarpal fractures on follow up, negating proposal to omit hands / feet on follow up

Bennett et al, 2011 2

Case series


Initial and repeat were full SS according to ACR standards, 19 images. Oblique views of ribs not routinely obtained.

9-56 days

All had normal initial SS, 4 (8.5%) had abnormal follow up SS. 3 rib fractures, 1 proximal humerus

Unusual inclusion criteria of only those with a completely negative SS, yet still showed additional forensically relevant fractures. No detail as to why these children underwent repeat imaging

Karmazyn et al, 2011 6

Cross sectional

930 children

109/116 equivocal fractures re-imaged


Full SS (31 views), including oblique views initially. Repeat imaging only for equivocal findings


29/116 (25%) definite fractures in previously equivocal findings

Retrospective study children < 2 years, 2003-2009

124/930 had new fractures on follow up. Main aim to propose reduced imaging for initial SS, propose excluding spine, pelvis, hands and feet, unless superficial injury to this area, as they accounted for 1% of fractures found. Cases described would suggest that some of these fractures were significant findings however

Sonik et al, 2010 10

Case series


Full SS, no oblique views ribs initially.

11/22 follow up full SS, 11 no repeat skull imaging

11-29 days (mean 16.7)

New fractures identified in 3/22 patients (13.6%), one in whom initial SS was normal

Retrospective study children < 2 years undergoing repeat SS, 2003-2007. No details as to why these children underwent repeat imaging. 3/22 new fractures, 1/6 initially normal fractures on repeat. Propose omitting AP pelvis and lateral spine. No oblique views, small numbers with no power calculation to support recommendation

Anilkumar et al, 2006 1

Case series



Initial SS (including oblique views if age < 1 year), follow up chest x-ray +/- oblique views

10 days – 3 weeks

3/59 (5.1%) had additional rib fractures noted on follow up

2/59 (3.4%) had rib fractures identified for the first time

Dating information was obtained in 3/59 patients (5.1%)

Retrospective study of children < 2 years, 1998-2003, routinely invited for follow up from 1/1/2000

Only 59/200 cases returned for follow up

Zimmerman et al, 2005 12

Prospective cohort


Initial and repeat were full SS, 19 images

Skull excluded from repeat survey

Mean 21.4 +/-9.7 days

22/48 children had additional information, 11 of whom had additional fractures identified. Additional fractures included rib, classic metaphyseal, clavicular, scapular, fibular and ulnar. One child in whom abuse was excluded by follow-up imaging

Prospective review between 1998 and 2000. Indications included all infants with suspected physical abuse who had multiple fractures, fractures of varying ages, fractures inconsistent with history, concern for abuse not diagnosed initially, abnormal initial SS. Only 48/74 (65%) of those called for follow-up attended

Kleinman et al, 1996 8

Retrospective cohort


Initial and repeat were full SS

Skull excluded from repeat survey, no obliques in first survey

14 days

13 children had 32 additional fractures identified. One initial SS was negative. Additional fractures included classic metaphyseal lesions, rib, spinal, pelvic and hand. Contributed to the dating of the injury for 13 of 70 fractures. One repeat confirmed original findings for a normal variant

Retrospective review between 1990 and 1995, indications for repeat SS included high suspicion of abuse, original imaging inconsistent with history

Hansen et al, 2014 3

Cross sectional


Full ACR skeletal survey at baseline and follow-up compared to limited view follow-up (excluding spine, pelvis, and skull)

10 – 42 days

The limited view follow-up would have missed eight spinal fractures in five children not visible on the original skeletal survey. All of these infants had additional fractures. Two infants had spinal fractures visible on chest view, two had further spinal abnormalities on initial skeletal survey and one had no other indications of spinal fracture. No pelvic fractures were identified on the follow-up SS that were not present on the initial SS. Those with pelvic fractures had a median of 7.5 other fractures.

This study would support the view that omitting pelvic images from the follow-up SS does not miss further fractures. Authors suggest omitting spinal views on the follow-up carries a low risk of missing significant spinal fractures


  • Williams describes a single case report of a six month old infant with an oblique fracture in the mid-diaphysis of the left femur. Bone scintigraphy indicated further fractures and repeat SS suggested a classic metaphyseal lesion on the right and left femur 11
  • Kellof et al’s study described a single case, a child of nine weeks of age with rib fractures not detected on first SS with oblique views 7
    • Identified on ultrasound initially; bilateral rib fractures seen on repeat SS at 14 days
  •  Harlan et al was previously included but has been excluded as 97 out of 101 cases in the original study have been re-reported in Hansen 3

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  1. Anilkumar A, Fender LJ, Broderick NJ, Somers JM, Halliday KE. The role of the follow-up chest radiograph in suspected non-accidental injury. Pediatric Radiology. 2006;36(3):216-218 [Pubmed]
  2. Bennett BL, Chua MS, Care M, Kachelmeyer A, Mahabee-Gittens M. Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal. BMC Research Notes. 2011;12(4):354. [Pubmed]

  3. Hansen KK, Keeshin BR, Flaherty E, Newton A, Passmore S, Prince J, Campbell KA. Sensitivity of the limited view follow-up skeletal survey. Pediatrics. 2014;134(2):242-248 [Pubmed]

  4. Harlan SR, Nixon GW, Campbell KA, Hansen K, Prince JS. Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed? Pediatric Radiology. 2009;39(9):962-968 [Pubmed]
  5. Harper NS, Eddleman S, Lindberg DM; ExSTRA Investigators. The utility of follow-up skeletal surveys in child abuse. Pediatrics. 2013;131(3):e672-e678 [Pubmed]

  6. Karmazyn B, Lewis ME, Jennings SG, Hibbard RA, Hicks RA. The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? American Journal of Roentgenology. 2011;197(1):W159-W163 [Pubmed]
  7. Kelloff J, Hulett R, Spivey M. Acute rib fracture diagnosis in an infant by US: a matter of child protection. Pediatric Radiology. 2009;39(1):70-72 [Pubmed]
  8. Kleinman PK, Nimkin K, Spevak MR, Rayder SM, Madansky DL, Shelton YA, Patterson MM. Follow-up skeletal surveys in suspected child abuse. American Journal of Roentgenology. 1996;167(4):893-896 [Pubmed]
  9. Singh R, Squires J, Fromkin JB, Berger RP. Assessing the use of follow-up skeletal surveys in children with suspected physical abuse. Journal of Trauma & Acute Care Surgery. 2012;73(4):972-976. [Pubmed]

  10. Sonik A, Stein-Wexler R, Rogers KK, Coulter KP, Wootton-Gorges SL. Follow-up skeletal surveys for suspected non-accidental trauma: can a more limited survey be performed without compromising diagnostic information? Child Abuse and Neglect. 2010;34(10):804-806 [Pubmed]
  11. Williams G, Treves ST. A second radiographic skeletal survey for child abuse triggered by bone scintigraphy found positive after the initial survey was called negative. Clinical Nuclear Medicine. 2007;32(1):29-31 [Pubmed]
  12. Zimmerman S, Makoroff K, Care M, Thomas A, Shapiro R. Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child Abuse and Neglect. 2005;29(10):1075-1083 [PubMed]


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