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Implications for practice

Which investigation has a higher yield, skeletal survey (SS) or radionuclide imaging (RNI)?

  • Either SS or RNI alone will miss occult fractures; optimal assessment should include both investigations

  • If RNI is the first line of investigation, an additional skull X-ray must be performed and coned views of the metaphyses should be considered

  • Confirmatory X-rays of abnormal areas on RNI should be performed

  • If SS is the first line of investigation, oblique views of the chest should be included
  • Consider repeat SS

 

Does repeat SS enhance detection?

  • Repeat SS increases the diagnostic yield and clarifies tentative findings from the first SS

  • Recent studies indicate that children with a negative first SS may have fractures on repeat SS that are of forensic importance

  • Consideration could be given to omitting pelvic and/or additional spinal views on follow-up SS
  • Repeat SS increases radiation dosage

  • Issues of uncertain child protection status between SS

 

What views should be included in a SS?

  • Radiological examination of the thorax should include oblique views

  • Separate views of the pelvis with high-detailed imagery, paying particular attention to pubic rami

  • High-detail, well-collimated posteroanterior views of hands and feet

  • Anteroposterior and lateral views of the entire spine

  • Consideration should be given to coned views around the knee to maximise detection of classic metaphyseal lesions

 

Which children with suspected abuse should be investigated for occult fractures?

  • Recent studies suggest that up to 12% of household contacts aged less than two may have a positive SS with twins being a particularly high risk 1

  • Not enough detail was available to comment on the likely benefit of SS in sexual abuse, neglect or older disabled children

  • Three studies described abusive fractures in older children, one who was disabled and two who had been physically and sexually abused 2-4

  • Two studies have now indicated that children with burns have a significant prevalence of occult fractures

 

What other imaging modalities may enhance detection of occult fractures?

  • If a CT brain is being undertaken, 3D reconstruction may help in delineating skull fractures

  • US is of value in identifying rib fractures in selected cases. CT may also identify rib fractures missed on four view plain films, however it has double the radiation dose of a full skeletal survey

 

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References

  1. Lindberg D, Sharpio R, Laskey A, Pallin, D, Blood E, Berger R, ExSTRA Investigators. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012;130(2):193-201. [Pubmed]

  2. Belfer RA, Klein BL, Orr L. Use of the skeletal survey in the evaluation of child maltreatment. The American Journal of Emergency Medicine. 2001;19(2):122-124 [Pubmed]
  3. Day F, Clegg S, McPhillips M, Mok J. A retrospective case series of skeletal surveys in children with suspected non-accidental injury. Journal of Clinical Forensic Medicine. 2006;13(2):55-59 [Pubmed]
  4. Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. American Journal of Diseases of Children. 1993;147(1):87-92 [Pubmed]



 

 

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