Bone Scintigraphy After a Negative Radiological Skeletal Survey Improves the Detection Rate of Inflicted Skeletal Injury in Children

Abstract

Background: Timely diagnosis of child physical abuse is of paramount importance. The added value of bone scintigraphy (BS) after a negative radiological skeletal survey (RSS) in children with suspected physical abuse has never been evaluated. Objective: The objective of this study was to assess the extent to which BS could improve the detection rate of skeletal injury in children with suspected physical abuse with an initial negative RSS. Methods: We used discharge codes to retrospectively identify children evaluated for suspected physical abuse in a university hospital (Nantes, France). We included all consecutive children younger than 3 years old who underwent both RSS and BS, with an interval of ≤96 h between tests, from 2013 to 2019. BS and RSS results were interpreted independently during the study period. We specifically analyzed BS results for children with a negative RSS to assess the value of BS as an add-on test. Results: Among the 268 children ≤3 years old with suspected physical abuse who underwent RSS, 140 (52%) also underwent BS within 96 h and were included in the analysis. The median age was 6 months old (interquartile range: 3-8). The detection rate of ≥1 skeletal injury with RSS alone was 49% (n = 69/140, 95% CI: 41-58%) vs. 58% (n = 81/140, 50-66%) with RSS followed by add-on BS, for an absolute increase in the detection rate of 9% points (95% CI: 4-14%). The number of children with a negative RSS who would need to undergo BS to detect one additional child with ≥1 skeletal injury was 6 (95% CI: 4-11). ADDED VALUE OF THIS STUDY Performing BS in young children with suspected physical abuse after a negative RSS would allow for a clinically significant improvement in the detection rate of skeletal injuries for a limited number of BS procedures required.

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

“… 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.…”