Broader Use of Skeletal Surveys May Help Diagnose Physical Abuse of Children

Laurie Barclay, MD

December 15, 2010

December 15, 2010 — Broader use of skeletal surveys may help diagnose physical abuse of children, according to the results of a retrospective, descriptive study reported online December 13 in Pediatrics.

"The skeletal survey (SS) is part of the evaluation of suspected physical abuse," write Shanna O. Duffy, BS, from Boonshoft School of Medicine, Wright State University in Dayton, Ohio, and colleagues. "Previous studies focused on the use of the SS for children whom the diagnosis of abuse was strongly suspected before completion of the SSs. This is the first study to describe the use of SSs in a large, consecutive population of children being evaluated because of concerns regarding physical abuse."

At a single children's hospital, 703 skeletal surveys were performed during a 4-year period. The investigators collected data regarding demographic and clinical factors, skeletal survey findings, and the effects of survey findings on clinical diagnoses. Such findings were considered to be positive when the skeletal survey detected a previously unsuspected fracture(s).

Results were positive in 76 (10.8%) of the skeletal surveys overall, with highest rates of positive results in children younger than 6 months, those with an apparent life-threatening event or seizure, and those with head trauma suspected to be from abuse. Of children with positive skeletal survey results, 79% had at least 1 healing fracture.

"The SS results influenced directly the decision to make a diagnosis of abuse for 50% of children with positive SS results," the study authors write. "These data, combined with the high morbidity rates for missed abuse and the large proportion of children with healing fractures detected through SS, suggest that broader use of SS, particularly for high-risk populations, may be warranted."

Limitations of this study include retrospective design, possible physician bias in the ordering of skeletal surveys, and unavoidable enrollment bias.

"This study used a restrictive definition of positive SS results (ie, finding of a fracture that was completely unsuspected) in a large sample and found a rate of positive SS results close to 11%," the study authors conclude. "Given the high morbidity and mortality rates of child abuse and our finding that the highest rate of positive SS results was for children <6 months of age, we recommend that a SS be completed for all infants <6 months of age for whom there is any suspicion of abuse. Additional data are needed to determine which subset of children presenting with [apparent life-threatening events] should undergo an SS."

The Summer Student Research Training Program of the Pediatric Clinical and Translational Research Center, Children's Hospital of Pittsburgh of UPMC, supported this study. The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online December 13, 2010.


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