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Other useful references

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.


Practice Guidelines


  • American and British guidelines for practice; neither address the role of radionuclide imaging but have specific guidance on views to be taken 1-4

  • Oblique views of the ribs are recommended when rib fractures are evident, and consideration should be given to including obliques in the standard survey protocol 4
  • Follow-up Skeletal Survey (SS) is recommended when there are abnormal or equivocal findings on the initial SS, or when abuse is suspected clinically 4
  • Addressing concerns about radiation dosage 5
  • Audit of UK SS three years after the British Society of Paediatric Radiology published their standards: only 15% included all appropriate views: technical quality considerably improved (score 9.7/11) 6
  • 40 studies in the US were assessed for the performance of SS or Radionuclide Imaging of children with suspected physical abuse aged less than two years or infants less than on year with non-vehicle associated head injury or femoral fractures 7
  • 83% of children less than two years old underwent appropriate screening, 68% of those aged less than one with a head injury and 77% of those less than one with a femoral fracture. Influential variables for appropriate screening were injury severity and year of admission 7

Alternative Imaging Techniques


  • Ultrasound (US) has been shown to be useful in detecting occult rib fractures in adults. These studies show an increased sensitivity of US over standard radiography, particularly in the cartilaginous portion of the rib 8,9

  • Evaluation of separation of the distal humerus epiphysis is well defined by US, particularly in neonates where ossification is minimal 10
  • The use of 18F-NaF positron emission tomography (PET) whole-body imaging is shown to demonstrate additional subtle fractures including classic metaphyseal lesion of the humerus and iliac crest fractures not seen on initial SS 11
  • Multi-planar computerised tomography scan (CT) and 3-dimensional (3D) image reconstructions may enhance the visualisation of rib fractures 12. However, even these imaging modalities may miss rib fractures as detailed in post-mortem studies 13,14
  • Post-mortem CT may also be of value in detecting incomplete buckle rib fractures 15
  • 3D CT images of the skull may enhance the distinction between normal variants and fractures 16
  • A study of 605 CT images of children aged 0-3 years highlighted that 53% had Wormian bones, the majority of which were multiple 17

Other potential indications for imaging


  • Multiple birth infants appear to be at higher risk of fractures or abdominal injuries than other siblings 18
  • An exploration of children presenting with a single extremity fracture, 37% of whom underwent neuroimaging, identified only 5 children (aged less than one year) with intracranial injury 19
  • In infants less than six months of age presenting to child abuse physicians with an isolated bruise, 23.3% had occult fractures identified on skeletal survey 20


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  1. Royal College of Radiologists. Standards for Radiological Investigations of Suspected Non-accidental Injury. Joint document produced in collaboration with the Royal College of Paediatrics and Child Health. London: RCR [Most recent version available to download from RCR website]
  2. American College of Radiology. Practice Guideline for Skeletal Surveys in Children (PDF). [Most recent version available to download from ACR website]
  3. British Society of Paediatric Radiology. Non-accidental injury standard for skeletal surveys [BSPR website]
  4. American Academy of Pediatrics: Di Pietro MA, Brody AS, Cassady CI, Kleinman PK, Wyly JB, Applegate KE, Wood BP, Zerin JM, Mercado-Deane MG, Seibert JJ, Stolic A. Policy statement: diagnostic imaging of child abuse. 2009;123(5):1430-1435 [Pubmed]
  5. Bury RF. The new ionising radiation regulations - will they make a difference? Imaging. 2000;12:255-261 [Abstract from BIR Journals]
  6. Swinson S, Tapp M, Brindley R, Chapman S, Offiah A, Johnson K. An audit of skeletal surveys for suspected non-accidental injury following publication of the British Society of Paediatric Radiology guidelines. Clinical Radiology. 2008;63(6):651-656 [Pubmed]
  7. Wood J, Feudtner C, Medina S, Xianqun L, Localio R, Rubin D. Variation in occult injury screening for children with suspected abuse in selected US children's hospitals. Pediatrics. 2012;130(5):853-860 [Pubmed]

  8. Mariacher-Gehler S, Michel BA. Sonography: a simple way to visualize rib fractures. American Journal of Roentgenology. 1994;163(5):1268 [Pubmed citation only]
  9. Kara M, Dikmen E, Erdal HH, Simsir I, Kara SA. Disclosure of unnoticed rib fractures with the use of ultrasonography in minor blunt chest trauma. European Journal of Cardio-Thoracic Surgery. 2003;24(4):608-613 [Pubmed]
  10. Fette A, Mayr J. Slipped distal humerus epiphysis in tiny infants easily detected and followed-up by ultrasound. Ultraschall in der Medizin. 2012;33(7):e361-e363 [Pubmed citation only]

  11. Drubach LA, Sapp MV, Laffin S, Kleinman PK. Fluorine-18 NaF PET imaging of child abuse. Pediatric Radiology. 2008;38(7);776-779 [Pubmed]
  12. Bixby SD, Abo A, Kleinman PK. High-impact trauma causing multiple posteromedial rib fractures in a child. Pediatric Emergency Care. 2011;27(3):218-219 [Pubmed]
  13. Dedouit F, Mallinger B, Guilbeau-Frugier C, Rougé D, Rousseau H, Telmon N. Lethal visceral traumatic injuries secondary to child abuse: a case of practical application of autopsy, radiological and microscopic studies. Forensic Science International. 2011;206(1-3):e62-66 [Pubmed]
  14. Hong TS, Reyes JA, Moineddin R, Chiasson DA, Berdon WE, Babyn PS. Value of postmortem thoracic CT over radiography in imaging of pediatric rib fractures. Pediatric Radiology. 2011;41(6):736-748 [Pubmed]
  15. Yang KM, Lynch M, O'Donnell C. "Buckle" rib fracture: an artifact following cardio-pulmonary resuscitation detected on postmortem CT. Legal Medicine. 2011;13(5):233-239 [Pubmed]
  16. Choudhary AK, Jha B, Boal DK, Dias M. Occipital sutures and its variations: the value of 3D-CT and how to differentiate it from fractures using 3D-CT? Surgical and Radiologic Anatomy. 2010;32(9):807-816 [Pubmed]
  17. Marti B, Sirinelli D, Maurin L, Carpentier E. Wormian bones in a general paediatric population. Diagnostic and Interventional Imaging. 2013;94(4):428-432.[Pubmed]

  18. Lang CA, Cox MJ1, Flores G2. Maltreatment in multiple-birth children. Child Abuse & Neglect. 2013;37(12):1109-13 [Pubmed]

  19. Wilson PM, Chua M, Care M, Greiner MV, Keeshin B, Bennett B. Utility of head computed tomography in children with a single extremity fracture. Journal of Pediatrics. 2014;164(6):1274-9 [Pubmed]

  20. Harper NS, Feldman KW, Sugar NF, Anderst JD, Lindberg DM. Additional injuries in young infants with concern for abuse and apparently isolated bruises.The Journal of Pediatrics. 2014;165(2):383-388 [Pubmed]


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