Add-on bone scintigraphy after negative radiological skeletal survey for the diagnosis of skeletal injury in children suspected of physical abuse: a systematic review and meta-analysis

Abstract

Objective(s)To systematically assess the extent to which bone scintigraphy (BS) could improve the detection rate of skeletal injury in children suspected of physical abuse with an initial negative radiological skeletal survey (RSS).Study designWe searched MEDLINE and Web of Science for series of ≥20 children suspected of physical abuse who underwent RSS and add-on BS. We assessed the risk of bias and the heterogeneity and performed random-effects meta-analyses.ResultsAfter screening 1140 unique search results, we reviewed 51 full-text articles, and included 7 studies (783 children, mostly ≤3 years old). All studies were of either high or unclear risk of bias. Substantial heterogeneity was observed in meta-analyses. The summary detection rate of skeletal injury with RSS alone was 52% (95% CI 37 to 68). The summary absolute increase in detection rate with add-on BS was 10 percentage points (95% CI 6 to 15); the summary relative detection rate was 1.19 (95% CI 1.13 to 1.25); the summary number of children with a negative RSS who needed to undergo a BS to detect one additional child with skeletal injury (number needed to test) was 3 (95% CI 2 to 7).ConclusionsFrom the available evidence, add-on BS in young children suspected of physical abuse with a negative RSS might allow for a clinically significant improvement of the detection rate of children with skeletal injury, for a limited number of BS procedures required. The quality of the reviewed evidence was low, pointing to the need for high-quality studies in this field.

Variations in Guidelines for Diagnosis of Child Physical Abuse in High-Income Countries

“…The guidelines were based on a limited number of well-designed primary studies, particularly for the definition and diagnosis of sentinel injuries, 14 , 50 the use of bone scintigraphy, 20 and laboratory tests 29 , 51 to perform in case of suspected CPA. The lack of primary studies may have led guidelines developers to opt for expert consensus rather than evidence-based guidelines, and this may explain the substantial heterogeneity among guidelines.…”

“… 55 , 56 , 57 , 58 , 59 Thus, an update of the oldest included guidelines would probably lead to more between-guideline consistency. Other systematic reviews have shown the complete lack of well-designed original studies, such as for bone scintigraphy, 20 pointing to the need to conduct such studies. There is also a clear need to define sentinel injuries, to agree not just on their location, size, patterns, and number but also on the term sentinel injury because it is not shared by all experts in the field of CPA.…”

“… 18 , 19 For example, we recently identified a between-guideline discrepancy for the imaging workup to be performed to detect skeletal injuries when CPA is suspected, notably the role of bone scintigraphy. 20 , 21 Identifying the specific fields for which guidelines lack completeness, clarity, or consistency for the early detection and diagnostic workup of CPA could help prioritize clinical questions requiring original diagnostic studies, systematic reviews (as performed in the aforementioned example of bone scintigraphy), 20 or an international consensus process. Our objective was to systematically investigate the completeness, clarity, and consistency of clinical guidelines for the early detection and diagnostic workup of CPA that were issued by academic societies and health agencies in high-income countries.…”

“…Lack of completeness, clarity, and consistency are among the reasons why clinical guidelines fail to standardize practices and thus mislead health professional practices . For example, we recently identified a between-guideline discrepancy for the imaging workup to be performed to detect skeletal injuries when CPA is suspected, notably the role of bone scintigraphy . Identifying the specific fields for which guidelines lack completeness, clarity, or consistency for the early detection and diagnostic workup of CPA could help prioritize clinical questions requiring original diagnostic studies, systematic reviews (as performed in the aforementioned example of bone scintigraphy), or an international consensus process.…”