The skeletal survey is an important imaging technique used in the evaluation of suspected child abuse. It is particularly helpful in the identification of fractures that are not clinically apparent in infants and young children. The American Academy of Pediatrics (AAP) recommends skeletal survey in cases of suspected child abuse for children less than 2 years of age. The AAP further recommends that the skeletal survey be repeated 2 weeks after the initial skeletal survey in cases in which child abuse is strongly suspected. The follow-up skeletal survey allows for identification of fractures that may have had too subtle a radiographic presentation to be seen when imaged acutely.
Objective The purpose of this study was to further clarify and assess the additional information gained from a repeat skeletal survey in identifying and characterizing skeletal injury for cases in which child abuse was strongly suspected.
Materials and Methods In this retrospective study, 27 infants and toddlers suspected of being physically abused had a recommended initial skeletal survey and underwent a follow-up examination approximately 2 weeks after the initial examination. The Child Protection Medical Team evaluated all children suspected of possible physical abuse. Nonaccidental trauma was determined by the Child Protection Medical Team. The medical records and radiologic reports of the 27 children with follow-up skeletal surveys were reviewed over a 3-year period. The number and location of the fractures were identified for the initial skeletal survey and for the follow-up skeletal survey in each case.
Results The follow-up skeletal survey yielded additional information regarding skeletal injury in 7 (29%) of 24 cases. A different pediatric radiologist evaluated the initial and subsequent repeated study in 19 of the 24 cases. In all but one of these cases, at least one fracture was visible on the initial study. Follow-up study increased the number of definite fractures detected from 72 to 82 (14%). These additional injuries were either rib fractures (30%) or long bone injuries (70%). The majority of the long bone injuries were classic metaphyseal lesions (5/7, 71%).
Conclusion A follow-up skeletal survey identified additional fractures or added additional information for findings in children who were suspected victims of physical abuse. It is recommended that a repeat skeletal survey 2 weeks after the initial skeletal survey be conducted for concerning cases of suspected child abuse. The addition of oblique views of the ribs may also enhance detection of occult rib fractures.
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