Prevalence and distribution of occult fractures on skeletal surveys in children with suspected non-accidental trauma imaged or reviewed in a tertiary Dutch hospital

Abstract

Purpose The purpose of the study was to determine the rate of occult fractures (without clinical symptoms) per presenting clinical injury i.e., children presenting with a fracture, bruise, abusive head trauma and the types of fracture most likely to be found, in a series of infants and young children suspected of being victims of NAT. Methods Skeletal surveys done between 2008 and 2018 of children (< 5 years) were retrospectively analyzed. Both radiographs of admitted children and reassessment images from all over the country were included and reviewed by a forensic paediatric radiologist. Deceased children were excluded. Variables as gender, age, initial clinical injury and occult fractures were collected. Occult fractures on the follow-up skeletal survey were collected. Results A total of 370 skeletal surveys of 296 children were included. Median age was 22 weeks (IQR 11-48), there were 172 (58%) boys. A total of 195 occult fractures were detected in 111 (32%) children. Occult fractures were detected in 37/126 (29%) children with fracture as presenting symptom, 33/90 (37%) children with head trauma and 26/50 (52%) children with bruises. Rib (n = 56, 50%) and lower leg (n = 40, 36%) fractures were most detected. Conclusion Occult fractures were detected in 32% of the children. Occult fractures were most prevalent if the initial clinical injury suggestive for NAT to request skeletal survey was a bruise, abusive head trauma or fracture. Keywords Non accidental injury • Paediatric injury • Fractures and dislocations • x-ray • Skeletal survey Abbreviations NAT Non-accidental trauma AHT Abusive head trauma MCF Metaphyseal corner fractures CAN, Child abuse and neglect team

Identification and Evaluation of Non-Accidental Trauma in the Pediatric Population: A Clinical Review

“…A skeletal survey (SS) is a core component in the workup of patients suspected of NAT that involves the evaluation of the entire skeletal system for fractures (Figure 2). For children under two years old or those unable to communicate due to disability, the SS is universally recommended [11,14,26,27]. There is no standardized number of views required for a SS, and guidelines vary from 17 to 32 views, with an average of 20 views [26,28].…”

“…In general, orthogonal views of the entire axial and appendicular skeleton are recommended. Additionally, oblique views of the ribs are almost universally recommended [10,[26][27][28][29][30]. Overall, this workup is considered low radiation with a dose of 0.2 mSV (millisievert) [28].…”

“…The diagnostic evaluation of rib fractures primarily involves radiography in the form of a skeletal survey (SS). Many experts advocate for the inclusion of oblique views in addition to anterior/posterior and lateral views in order to increase the sensitivity of radiographs [10,[27][28][29][30]. Even with these additional views, rib fractures can still be missed on initial SS 16-66% of the time [28].…”

Asymptomatic Infant Rib Fractures Are Primarily Non-abuse-Related and Should Not Be Used to Assess Physical Child Abuse

“…If the placenta is malfunctioning, for example in cases of a serious chronic histiocytic intervillositis with a massive perivillous fibrin deposition [42][43][44], the reported incidences are (1), in 6 of 10,000 2nd and 3rd trimester placentas [42] versus (2), in 20 diagnoses of 22,000 births over a 6 years period [44], or 20/22,000 ≈ 9.1/10,000 births. An average estimated incidence then follows as (6 + 20)/(10,000 + 22,000) ≈ 8.1/10,000 births.…”

“…For many years, the identification of such occult asymptomatic rib fractures in infants was frequently an undisputed sign that physical child abuse had taken place. However, it was ignored that occult asymptomatic rib fractures occur frequently in infants, e.g., [1][2][3]. It is therefore essential to be able to distinguish between different causes of infant rib fractures.…”