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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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  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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