The Prevalence of Uncommon Fractures on Skeletal Surveys Performed to Evaluate for Suspected Abuse in 930 Children: Should Practice Guidelines Change?

Karmazyn, Boaz; Lewis, Max E.; Jennings, S. Gregory; Hibbard, Roberta A.; Hicks, Ralph A.

doi:10.2214/ajr.10.5733

Cited by 83 publications

(52 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…[15][16][17][18][19][20][21][22][23][24][25][26][27][28] The small number of these fractures, and their frequent association with other evidence allowing the diagnosis of abuse, has triggered a suggestion that spine and pelvis views be omitted from SS1. 24,26 Others have opposed this viewpoint for spine fractures, 25,27,28 making the argument that there is high specificity for abuse when occult spine fractures are discovered, and that spine fractures, while uncommon, are not rare. The low initial prevalence of spine and pelvis fractures on both SS1 and SS2 supports decreasing repeated exposure by eliminating these views from SS2.…”

Section: Discussionmentioning

confidence: 99%

Sensitivity of the Limited View Follow-up Skeletal Survey

et al. 2014

View full text Add to dashboard Cite

BACKGROUND AND OBJECTIVE: Reducing radiation exposure to minimize risk has been emphasized in recent years. In child abuse, the risk of missing occult injuries is often believed to outweigh radiation risk associated with skeletal surveys. Our hypothesis was that there would be no clinically significant difference in results from a limited view, follow-up skeletal survey (SS2) protocol, which omits spine and pelvis views unless these views have findings on the initial skeletal survey (SS1), compared with a traditional SS2 protocol for radiographic evaluation of suspected physical abuse. METHODS: This study was a retrospective record review involving 5 child protection teams. Consultations for suspected physical abuse were reviewed to identify subjects <24 months of age who had an SS1 and a traditional SS2. The results of these studies were compared to identify subjects in which newly identified spine and pelvis fractures (fractures seen only on SS2 and not on SS1) would have been missed by using a limited view SS2 protocol. RESULTS: We identified 534 study subjects. Five subjects had newly identified spine fractures, and no subjects had newly identified pelvis fractures on traditional SS2 studies. Only 1 subject with a newly identified spine fracture would have been missed with the limited view SS2 protocol used in this study (0.2% [95% confidence interval: <0.005–1.0]). None of the newly identified fractures changed the abuse-related diagnosis. CONCLUSIONS: We found no clinically significant difference in the results of a limited view SS2 protocol versus a traditional SS2 protocol for radiographic evaluation of suspected abuse.

show abstract

Section: Discussionmentioning

confidence: 99%

Sensitivity of the Limited View Follow-up Skeletal Survey

et al. 2014

View full text Add to dashboard Cite

show abstract

“…A similar study reported that SSs revealed additional fractures in 13% (124 of 930) of children ,2 years old evaluated for suspected abuse. 11 Even higher incidences (25%-30%) of occult fractures have been reported in studies of children ,2 years old diagnosed with physical abuse. 12,13 Given the substantial likelihood of occult fractures in young victims of physical abuse, the American Academy of Pediatrics recommends performing SS in all cases of suspected physical abuse in children ,2 years old, but not in cases in which abuse and occult fractures are unlikely.…”

Section: What This Study Addsmentioning

confidence: 96%

“…This supplemental review identified 18 relevant articles from which data were abstracted and summarized for the expert panel. [10][11][12][13][23][24][25][26][27][28][29][30][31][32][33][34][35][36] …”

Section: Literature Reviewmentioning

confidence: 99%

Development of Hospital-Based Guidelines for Skeletal Survey in Young Children With Bruises

2015

PEDIATRICS

View full text Add to dashboard Cite

OBJECTIVE: To develop guidelines for performing an initial skeletal survey (SS) for children ,24 months of age presenting with bruising in the hospital setting, combining available evidence with expert opinion. METHODS:Applying the Rand/UCLA Appropriateness Method, a multispecialty panel of 10 experts relied on evidence from the literature and their own clinical expertise in rating the appropriateness of performing SS for 198 clinical scenarios characterizing children ,24 months old with bruising. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 219 revised scenarios. For the 136 clinical scenarios in which SS was deemed appropriate, the panel finally assessed the necessity of SS.RESULTS: Panelists agreed that SS is "appropriate" for 62% (136/219) of scenarios, and "inappropriate" for children $12 months old with nonpatterned bruising on bony prominences. Panelists agreed that SS is "necessary" for 95% (129/136) of the appropriate scenarios. SS was deemed necessary for infants ,6 months old regardless of bruise location, with rare exceptions, but the necessity of SS in older children depends on bruise location. According to the panelists, bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttock, or genital area necessitates SS in children ,12 months. CONCLUSIONS:The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising. WHAT'S KNOWN ON THIS SUBJECT:Bruising is common in young victims of physical abuse as well as in cases of accidental trauma. There is uncertainty regarding which young children with bruising require evaluation with skeletal survey for possible abuse. WHAT THIS STUDY ADDS:The results of this study provide guidelines, based on the literature and knowledge of experts, for identifying children ,24 months presenting for care in the hospital setting with bruises, who should and should not undergo skeletal survey.

show abstract

“…SSs reveal fractures that are not clinically suspected on the basis of history or physical examination in 10% to 40% of children ,2 years old evaluated for suspected abuse. [1][2][3][4][5][6] In addition to identifying fractures requiring medical treatment, SSs can document fractures and other findings that do not require medical treatment but are important to safeguard the well-being of the child. Specific patterns of fractures can confirm a diagnosis of abuse and allow for protection of the child.…”

Section: What This Study Addsmentioning

confidence: 99%

Evaluation for Occult Fractures in Injured Children

2015

PEDIATRICS

View full text Add to dashboard Cite

OBJECTIVES: To examine variation across US hospitals in evaluation for occult fractures in (1) children ,2 years old diagnosed with physical abuse and (2) infants ,1 year old with injuries associated with a high likelihood of abuse and to identify factors associated with such variation. METHODS:We performed a retrospective study in children ,2 years old with a diagnosis of physical abuse and in infants ,1 year old with non-motor vehicle crash-related traumatic brain injury or femur fractures discharged from 366 hospitals in the Premier database from 2009 to 2013. We examined across-hospital variation and identified child-and hospital-level factors associated with evaluation for occult fractures.RESULTS: Evaluations for occult fractures were performed in 48% of the 2502 children with an abuse diagnosis, in 51% of the 1574 infants with traumatic brain injury, and in 53% of the 859 infants with femur fractures. Hospitals varied substantially with regard to their rates of evaluation for occult fractures in all 3 groups. Occult fracture evaluations were more likely to be performed at teaching hospitals than at nonteaching hospitals (all P , .001). The hospital-level annual volume of young, injured children was associated with the probability of occult fracture evaluation, such that hospitals treating more young, injured patients were more likely to evaluate for occult fractures (all P , .001).CONCLUSIONS: Substantial variation in evaluation for occult fractures among young children with a diagnosis of abuse or injuries associated with a high likelihood of abuse highlights opportunities for quality improvement in this vulnerable population.WHAT'S KNOWN ON THIS SUBJECT: Screening for occult fractures is a key component of the medical evaluation for young victims of suspected physical abuse. Little is known about adherence to occult fracture evaluation guidelines in children with suspected abuse cared for at non-pediatric-focused hospitals.WHAT THIS STUDY ADDS: Occult fracture evaluations were performed in half of young children diagnosed with abuse or injuries concerning for abuse in a large cohort of hospitals. Evaluations were more common at hospitals caring for higher volumes of young, injured children.

show abstract

The Prevalence of Uncommon Fractures on Skeletal Surveys Performed to Evaluate for Suspected Abuse in 930 Children: Should Practice Guidelines Change?

Cited by 83 publications

References 16 publications

Sensitivity of the Limited View Follow-up Skeletal Survey

Sensitivity of the Limited View Follow-up Skeletal Survey

Development of Hospital-Based Guidelines for Skeletal Survey in Young Children With Bruises

Evaluation for Occult Fractures in Injured Children

Contact Info

Product

Resources

About