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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, 18 studies addressed which children should be investigated for occult fractures when child abuse is suspected 1-18

  • Study design:
    • 5 case series 1,2,6,7,13
    • 10 cross-sectional 3-5,8,10,12,14-16,18
    • 2 uncontrolled before and after study 9,17 
    • 1 cohort study 11
  • Age range: 0 – 16 years (the majority were aged less than two years)
  • Gender: the rate of positive SS was not analysed by gender


Influence of ethnicity and socio-economic group

  • African/American infants with unwitnessed head injury were more likely to have a SS than white infants (90.5% v 69.3%, p=0.01) 17. Non-white or hispanic children or those without private insurance were more likely to undergo screening 9,14 
  • White children with private insurance were much less likely to have a SS than white children with no insurance/government insurance (50% v 88%, p<0.001) 17,18
  • Introduction of a screening guideline reduced the inequities in SS conducted in white versus African/American children (rates of SS in white children increased from 69.3% to 84.6%, (p=0.05) but stayed the same among African/American children) 9,17 


Details of included studies

Influence of age on fracture detection

  • The diagnostic yield from SS correlates inversely with age and is significant for children under two years of age 1,2,4,5,8,12,13,16 
  • The rate of occult fractures detected in children aged less than two years in two large-scale studies was 10% – 13% 4,10,13
  • There is a higher diagnostic rate for SS in children under six months than in those aged two years and six months 4
  • Two studies showed no difference in the yield of occult findings on SS in those aged less than one year and those aged one – two years 6,13
  • Significantly more rib fractures 7 and classical metaphyseal lesions 7,13 were found in children aged less than one year than those aged one – two years 
  • 14/17 (82%) of positive SS were in children less than one year of age 2
  • 14/55 (25%) of children aged less than one year had positive SS 2
  • Only 2/7 (29%) of children aged between one and two years had positive SS (personal correspondence) 2

Screening siblings/household contacts

  • Six skeletal surveys were performed on siblings (< three years old) of children with abuse. SS was positive in one sibling 2
  • 134 household contacts aged less than two years underwent a SS. 16/134 had fractures, 9 of whom were aged less than six months 15
  • Half of these children had an isolated fracture and half multiple fractures, none of which had clinical signs 15
  • 9/16 twins had fractures on their SS giving an odds ratio of 20.1, 95% CI 5.8-69.9 for identifying a fracture in a twin of an abused child 15.  Of 75 twin triplet siblings screened, twins were more likely to have an occult fracture identified than non-twins 14


Indications for SS

  • 14% of children with abusive burns had occult fractures identified on SS 6,8
  • Mean age of children with positive SS and burns was older than non-burns cases (p=0.03) 8
  • Fractures in children with burns included rib, CML, long bone, skull, and clavicular 6


  • 29% of infants aged less than one year with an unwitnessed head injury had positive findings on SS warranting child protection investigations 17
  • If the injury severity score was >15, cases were more likely to have positive findings than those with lower scores (OR 3.4, p<0.01) 17
  • Abusive head trauma (AHT) was significantly associated with a positive SS (P<0.00) 4
  • Three children presenting with an isolated skull fracture and no other signs of abuse had a positive SS 4
  • 86% of children aged less than 18 months presenting with an isolated skull fracture underwent SS, of whom 6% had an additional fracture identified. Only one of nine with additional fractures was aged more than 6 months, eight of nine had a simple skull fracture 11
  • Of 201 children less than one year of age presenting with skull fracture and a normal GCS, 12 had further fractures (5.5%) 3
  • 141 infants aged less than one year presenting with a skull fracture (non-MVC) underwent SS with only two identifying additional fractures. Each had risk factors for child abuse. Additional fractures were lower limb metaphyseal fractures 18


  • Children presenting with apparent life threatening event (ALTE) / apnoea had a higher rate of positive SS than those presenting for other reasons (p=0.05) 4
  • Children presenting with seizure had a higher rate of positive SS than those presenting for other reasons (p=0.02) 4


 Details of Reference 19 are not given here due to possible overlapping data with study 14



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  1. 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]
  2. 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]
  3. Deye KP, Berger RP, Lindberg DM; ExSTRA Investigators. Occult abusive injuries in infants with apparently isolated skull fractures. Journal of Trauma & Acute Care Surgery. 2013;74(6):1553-1558 [Pubmed]

  4. Duffy SO, Squires J, Fromkin JB, Berger RP. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics. 2011;127(1):e47-e52 [Pubmed]
  5. Ellerstein NS, Norris KJ. Value of radiologic skeletal survey in assessment of abused children. Pediatrics 1984;74(6):1075-1078 [Pubmed]
  6. Fagen KE, Shalaby-Rana E, Jackson AM.Frequency of skeletal injuries in children with inflicted burns. Pediatric Radiology. 2015;45(3):396-401 [Pubmed]

  7. Hansen KK, Campbell KA. How useful are skeletal surveys in the second year of life? Child Abuse and Neglect. 2009;33(5):278-281 [Pubmed citation only]
  8. Hicks RA, Stolfi A. Skeletal surveys in children with burns caused by child abuse. Pediatric Emergency Care. 2007;23(5):308-313 [Pubmed]
  9. Higginbotham N, Lawson KA, Gettig K, Roth J, Hopper E, Higginbotham E, George TM, Maxson T, Edwards G, Garcia NM. Utility of a child abuse screening guideline in an urban pediatric emergency department. The Journal of Trauma and Acute Care Surgery. 2014;76(3):871-877 [Pubmed]

  10. 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]
  11. Laskey AL, Stump TE, Hicks RA, Smith JL. Yield of skeletal surveys in children < 18 months of age presenting with isolated skull fractures. Journal of Pediatrics. 2013;162(1):86-89. [Pubmed]

  12. 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]
  13. Lindberg DM, Berger RP, Reynolds MS, Alwan RM, Harper NS; Examining Siblings To Recognize Abuse Investigators. Yield of skeletal survey by age in children referred to abuse specialists. The Journal of Pediatrics. 2014;164(6):1268-1273 [Pubmed]

  14. Lindberg DM, Blood EA, Campbell KA, Laskey AL, Berger RP; Examining Siblings to Recognize Abuse Study Group. Predictors of screening and injury in contacts of physically abused children. Journal of Pediatrics. 2013;163(3):730-735. e1-e3 [Pubmed]

  15. 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]

  16. Merten DF, Radlowski MA, Leonidas JC. The abused child: a radiological reappraisal. Radiology. 1983;146(2):377-381 [Pubmed]
  17. Rangel EL, Cook BS, Bennett BL, Shebesta K, Ying J, Falcone RA. Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline. Journal of Pediatric Surgery. 2009;44(6):1229-1234; discussion 1234-5 [Pubmed]
  18. Wood JN, Christian CW, Adams CM, Rubin DM. Skeletal surveys in infants with isolated skull fractures. Pediatrics. 2009;123(2):e247-52 [Pubmed]

  19. Lindberg DM, Harper NS, Laskey AL, Berger RP; ExSTRA Investigators. Prevalence of abusive fractures of the hands, feet, spine, or pelvis on skeletal survey: perhaps "uncommon" is more common than suggested. Pediatric Emergency Care. 2013;29(1):26-9 [Pubmed]


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