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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, 20 studies addressed the issue 1-20
  • Study design:
    • 11 case study / case series 1-4,6,7,9,11,16,18-20 
    • 6 cross-sectional 5,10,12-14,17
    • 2 randomised control trial 8,15
  • Age range: 0 -16  years, the majority of the children less than two years of age 10,12-14
  • Gender: data not analysed by gender
  • No study addressed radiological investigations of disabled children
  • No study addressed the influence of ethnicity and socio-economic group


Details of included studies

Benefit of oblique views of the chest

  • Three studies showed significant benefit of oblique views of the chest 7,8,15
    • Comparison of two view chest X-ray (anteroposterior and lateral) with a four view assessment including two additional oblique views of the ribs in 73 children 8
    • Sensitivity improved by 17% (95% confidence interval (CI) 2-36%), p=0.18 8. 
    • Specificity improved by 7% (95% CI 2-13%), p=0.004 8
    • The average improvement for diagnostic accuracy between three radiologists was 9% (CI 5-16%), p=0.005 8
    • Three children had rib fractures that were only seen on oblique films 8
    • The addition of oblique views increased detection rate by 19% 15
    • This study was evaluating the benefit of oblique views in addition to a standard ACR skeletal survey in infants who all had at least one rib fracture 15
    • The four view differed in the number of rib fractures detected in comparison to the two view (p=0.02) 7
    • The additional fractures noted/excluded were predominantly posterior and lateral 7


Less common abusive fractures

  • 16 studies recorded abusive fractures in less common sites and 15/16 stress the importance of specific radiological views: 1-6,9-11,13,14,16-20
    • Pelvic fractures are recorded in association with multiple injury or sexual abuse 1,5,11,13,17,20
    • Occult fractures of the hands and feet, predominantly torus fractures are described 9,13,16,18
    • Spinal fractures and fracture dislocations described, and may be occult even if unstable 3,4,6,13,19. One study noted only 1/530 children had compression fractures of the spine, presenting with paraplegia 10
  • Four studies questioned the value of screening for rarer fractures.
    • One study noted that all children with these rarer fractures had either clinical findings or multiple additional fractures elsewhere 13. This study included 11 additional views, limiting its applicability to those undergoing a standard SS
    • One study noted no pelvic, one spinal and nine fractures to the feet amongst 530 children screened. This study highlighted the radiation dose of pelvic imaging, and recommended omitting the pelvis 10
    • One study noted 5.5% of 365 children had fractures to the spine, hands and feet. 25 spinal fractures were noted in ten children, from Hangmans fracture at C2 to sacral fractures, all but one had associated non-spinal injuries. 1.4% of SS had hand fractures and 1.6% fractured feet 14
    • 14/751 children had spinal fractures. Four children had co-existent injuries. 4/14 were aged two to four years and seven had multiple spinal fractures 2

Benefits of lateral views in addition to standard frontal views of long bones 12

  • Significantly more metaphyseal fractures were seen on combined frontal and lateral views (p<0.01)

  • No significant difference for diaphyseal fractures
  • Levels of agreement between radiologists improved the addition of lateral views, especially in metaphyseal fractures
  • Recommendation of the inclusion of coned metaphyseal views of knees and ankles within skeletal survey

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  1. Ablin DS, Greenspan A, Reinhart MA. Pelvic injuries in child abuse. Pediatric Radiology. 1992;22(6):454-457 [Pubmed]
  2. Barber I, Perez-Rossello JM, Wilson CR, Silvera MV, Kleinman PK. Prevalence and relevance of pediatric spinal fractures in suspected child abuse. Pediatric Radiology. 2013;43(11):1507-15 [Pubmed]

  3. Carrion WV, Dormans JP, Drummond DS, Christofersen MR. Circumferential growth plate fracture of the thoracolumbar spine from child abuse. Journal of Pediatric Orthopaedics. 1996;16(2):210-214 [Pubmed]
  4. Diamond P, Hansen CM, Christofersen MR. Child abuse presenting as a thoracolumbar spinal fracture dislocation: a case report. Pediatric Emergency Care. 1994;10(2):83-86 [Pubmed]
  5. Ellerstein NS, Norris KJ. Value of radiologic skeletal survey in assessment of abused children. Pediatrics 1984;74(6):1075-1078 [Pubmed]
  6. Gabos PG, Tuten HR, Leet A, Stanton RP. Fracture-dislocation of the lumbar spine in an abused child. Pediatrics. 1998;101(3 Pt 1):473-477 [Pubmed citation only]
  7. Hansen KK, Prince JS, Nixon GW. Oblique chest views as a routine part of skeletal surveys performed for possible physical abuse--is this practice worthwhile? Child Abuse and Neglect. 2008;32(1):155-159 [Pubmed]
  8. Ingram JD, Connell J, Hay TC, Strain JD, Mackenzie T. Oblique radiographs of the chest in nonaccidental trauma. Emergency Radiology. 2000;7(1):42-46 [Abstract from Springer Link]
  9. Jaffe AC, Lasser DH. Multiple metatarsal fractures in child abuse. Pediatrics. 1977;60(4 Pt 2):642-643 [Pubmed citation only]
  10. Jha P, Stein-Wexler R, Coulter K, Seibert A, Li CS, Wootton-Gorges SL. Optimizing bone surveys performed for suspected non-accidental trauma with attention to maximizing diagnostic yield while minimizing radiation exposure: utility of pelvic and lateral radiographs. Pediatric Radiology. 2013;43(6):668-72 [Pubmed]

  11. Johnson K, Chapman S, Hall CM. Skeletal injuries associated with sexual abuse. Pediatric Radiology. 2004; 34(8):620-623 [Pubmed]
  12. Karmazyn B, Duhn RD, Jennings SG, Wanner MR, Tahir B, Hibbard R, Hicks R. Long bone fracture detection in suspected child abuse: contribution of lateral views. Pediatric Radiology. 2012;42(4):463-469 [Pubmed]
  13. 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]
  14. Kleinman PK, Morris NB, Makris J, Moles RL, Kleinman PL. Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse. American Journal of Roentgenology. 2013;200(3):641-4 [Pubmed]

  15. Marine MB, Corea D, Steenburg SD, Wanner M, Eckert GJ, Jennings SG, Karmazyn B. Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified? AJR. American Journal of Roentgenology. 2014;202(4):868-871 [Pubmed]

  16. Merten DF, Kirks DR, Ruderman RJ. Occult humeral epiphyseal fracture in battered infants. Pediatric Radiology. 1981;10(3):151-154 [Pubmed]
  17. Merten DF, Radlowski MA, Leonidas JC. The abused child: a radiological reappraisal. Radiology. 1983;146(2):377-381 [Pubmed]
  18. Nimkin K, Spevak MR, Kleinman PK. Fractures of the hands and feet in child abuse: imaging and pathological features. Radiology. 1997;203(1):233-236 [Pubmed]
  19. Rooks VJ, Sisler C, Burton B. Cervical spine injury in child abuse: report of two cases. Pediatric Radiology. 1998;28(3):193-195 [Pubmed]
  20. Starling SP, Heller RM, Jenny C. Pelvic fractures in infants as a sign of physical abuse. Child Abuse and Neglect. 2002;26(5):475-480 [Pubmed]



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