NEW YORK (Reuters Health) – Skeletal surveys are often critical to the diagnosis of physical abuse in children, researchers report in the December 13th online issue of Pediatrics.

“When physicians are evaluating infants and young children with a fracture, with an apparent life-threatening event (ALTE), with non-specific symptoms such as fussiness, or with a seizure, they should consider the possibility of physical abuse and the potential usefulness of a skeletal survey in helping them determine the cause of the child’s symptoms,” Dr. Rachel P. Berger, from Children’s Hospital of Pittsburgh of UPMC, told Reuters Health in an email. “The younger the child, the more likely the skeletal survey is to demonstrate an unsuspected fracture.”

Dr. Berger and colleagues describe the use of the skeletal survey to screen for clinically unsuspected fractures in a retrospective study of 1147 children, 703 of whom were ultimately included in the study.

The most common reason for the skeletal survey was recognized fracture (37%), followed by features of child abuse (19%).

Seventy-six (10.8%) of the skeletal surveys yielded positive results, and children under 6 months of age had a higher rate of positive results (16.4%) than did children over 6 months of age (6.8%).

Skeletal survey results were even more likely to be positive among children who presented to the hospital with an ALTE (18.2%) or seizure (33%).

Of the children with positive skeletal survey results, 42 (55%) had a single fracture, 18 (24%) had 2 fractures, and 16 (21%) had 3 or more fractures.

Forty-nine (79%) of 62 children for whom fracture age was noted by the radiologist had at least 1 healing fracture, whereas 13 children (21%) had only acute fractures.

In half of the cases where the skeletal survey results were positive, the results directly influenced the decision to make a diagnosis of abuse. In the other half of the positive cases, either a diagnosis of abuse was not made or a diagnosis of abuse would have been made regardless of the survey results.

“The radiation risk from a skeletal survey, particularly when performed in a hospital that uses a radiation dose as low as reasonably achievable, is significantly lower than the radiation risk from many of the other screening tools we routinely use in medicine,” Dr. Berger explained. “The benefit of a skeletal survey is far greater than many of the screening tools we use; a skeletal survey can potentially save the life of an infant or young child.”

“In our study, half of the cases in which the skeletal survey showed unsuspected fractures, the diagnosis of abuse was only able to be made because of the results of the skeletal survey,” Dr. Berger said. “Because of these results, the children were protected from being returned to an abusive environment, and future abuse and possibly death.”

“Child physical abuse is an important cause of morbidity and mortality in infants and young children,” Dr. Berger added. “Additional research is needed to better understand which children should undergo a skeletal survey for symptoms such as fussiness, a seizure, or an ALTE.”

Reference:
Use of Skeletal Surveys to Evaluate for Physical Abuse: Analysis of 703 Consecutive Skeletal Surveys
Pediatrics 2011;127:e47-e52.