Of 490 studies reviewed, ten studies addressed which children should be investigated for occult fractures when child abuse is suspected ^1-10

• Study design:
• 3 case series ^1,2,5
• 6 cross-sectional ^3,4,6-9
• 1 uncontrolled before and after study ¹⁰
• Total data: 3587 children who had skeletal survey (SS)
• Age range: 0 – 16 years (1110 less than one year old, where data available)
• 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) ¹⁰
  
• 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) ¹⁰
  
• 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) ¹⁰
  

 

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^1-4,6,8,9
• The rate of occult fractures detected in children aged less than two years in two large-scale studies was 11% ³, 13% ⁷
  
• There is a higher diagnostic rate for SS in children under six months than in those aged two years and six months  ³
  
• One study showed no difference in the yield of occult findings on SS in those aged less than one year (23% positive, 95% confidence interval (CI) 18, 28) and those aged one – two years (19% positive 95% CI 11, 29), p=0.45 ⁵
  
• Significantly more rib fractures and classical metaphyseal lesions were found in children aged less than one year than those aged one – two years ⁵
  
• 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
• Six skeletal surveys were performed on siblings (< three years old) of children with abuse. SS was positive in one sibling ²
  

 

Indications for SS

• 14% of children with abusive burns had occult fractures identified on SS ⁶
  
• Mean age of children with positive SS and burns was older than non-burns cases (p=0.03) ⁶
  

• 29% of infants aged less than one year with an unwitnessed head injury had positive findings on SS warranting child protection investigations ¹⁰
  
• 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) ¹⁰
  
• Abusive head trauma (AHT) was significantly associated with a positive SS (P<0.00) ³

• 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) ³
• Children presenting with seizure had a higher rate of positive SS than those presenting for other reasons (p=0.02) ³

• Three children presenting with an isolate skull fracture and no other signs of abuse had a positive SS ³