Skeletal Survey Guidelines for Toddler Fractures Issued

Larry Hand

June 16, 2014

An expert panel has issued new skeletal survey (SS) guidelines for clinicians trying to decide whether fractures in children younger than 2 years may have resulted from abuse or accidents.

The guidelines are aimed at reducing the wide variation among hospitals in the frequency of performing SS, reducing the racial and socioeconomic disparities that result in under- or overuse of the procedure, and increasing detection of abuse cases.

Joanne N. Wood, MD, MSHP, from the Division of General Pediatrics and PolicyLab, Children's Hospital of Philadelphia, Pennsylvania, and colleagues detail the new guidelines in an article published online June 16 in Pediatrics.

The panel of 13 experts, representing multiple specialties, conducted a literature review, developed a list of clinical scenarios based on the review, and then, in a series of discussions and electronic communications, rated the scenarios as to whether SS is appropriate or necessary. The panel concluded that of 240 scenarios, SS is appropriate in 191 scenarios (80%) and necessary in 175 (92%) of the appropriate scenarios.

The American Academy of Pediatrics (AAP) recommends performing SS in cases of suspected physical abuse in children younger than 2 years, although AAP advises against exposing children to radiation in cases unlikely to find old injuries that failed to show up on regular examination or radiographs.

Earlier this year, AAP published guidance in an updated report on factors to consider in identifying possible abuse cases, and the new scenario guidelines add to that base.

In general, the panelists agreed that:

  • SS should be performed when a fracture results from abuse, domestic violence, or being hit by a toy or other object;

  • SS should be performed in cases with rib fractures and in children without a history of fracture from trauma, "except in the ambulatory child ≥12 months old with a toddler fracture or buckle fracture of the radius/ulna or tibia/fibula"; and

  • SS should be performed almost universally in children younger than 12 months.

The panelists also agreed that SS should not be performed in 2 specific cases if no abuse is suspected:

  • "Distal spiral fracture of the tibia/fibula in a child 12–23 months old with a history of fall while running/walking," or

  • "Distal radial/ulna buckle feature in an ambulatory child 12–23 months old with a history of a fall onto an outstretched hand."

"Given the significant risk of abuse among children <12 months old with fractures, it is not surprising that these guidelines, like the AAP recommendations, advocate for almost universal SS screening in this population," the authors write. "Current clinical practices, however, diverge from these guidelines."

The new study results "provide a set of explicit consensus guidelines for performing initial SS in children with fractures," they write.

This research was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health. Dr. Wood’s institution has received payment for expert witness court testimony that Dr. Wood has provided in cases of suspected child abuse. The other authors have disclosed no relevant financial relationships.

Pediatrics. Published online June 16, 2014. Abstract

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