Monday, 27 December 2010

CHILD ABUSE: Broader Use of Skeletal Surveys May Help Diagnose Physical Abuse of Children

News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

In the May 2009 issue of Pediatrics, the American Academy of Pediatrics recommended a skeletal survey for all children younger than 2 years who are suspected of being physically abused and for selected children 2 to 5 years old. Studies on the use of skeletal surveys usually include children for whom there is a strong suspicion or diagnosis of abuse. For example, in the February 1983 issue of Radiology, Merten and colleagues reported that 33% of children for whom there was a strong suspicion or diagnosis of abuse had fractures identified on skeletal survey.
This retrospective, descriptive study assesses the use of the skeletal survey to screen for clinically unsuspected fractures in consecutive children who presented to the hospital.

Study Highlights

  • Of 1147 children who had a skeletal survey during the 4-year study period, 703 children who presented for concerns regarding physical abuse were eligible.
  • Exclusion criteria were skeletal surveys ordered for other than suspected abuse or for an undetermined reason.
  • Chart review extracted data on sex, age, reason for presentation, reason for skeletal survey, and survey results.
  • Median age of the children was 8 months (range, 4 days to 12 years).
  • Age categories were younger than 6 months, 6 to 11.9 months, 12 to 23.9 months, 24 to 58.9 months, and older than 59 months.
  • 84% of children were younger than 2 years, 15% were 2 to 5 years old, and 1% were older than 5 years.
  • 57% were boys.
  • 97.2% of patients had a skeletal survey in the emergency department or other outpatient location.
  • A positive result was defined as a fracture that was not suspected clinically or recognized previously.
  • The child protection team classified positive skeletal survey results as definite, probable, possible, or no abuse.
  • Analysis categories of skeletal survey results were abuse (definite or probable) or no abuse (possible or no abuse).
  • An investigator reviewed the charts for skeletal survey–positive cases to determine whether the survey results influenced the diagnosis of abuse.
  • Skeletal survey results affected the diagnosis if the results changed the diagnosis from possible to probable or definite abuse.
  • Such results did not affect the diagnosis if definite or probable abuse was not diagnosed, despite positive skeletal survey results and if abuse would be diagnosed even if the skeletal survey results were negative.
  • Possible skeletal survey fracture results were positive if confirmed with radiographs or bone scans and negative if follow-up testing did not confirm fracture, was not performed, or was inconclusive.
  • The most common reasons for presentation to the hospital were trauma in 35% and symptoms of injury in 21%.
  • The most common reason for a skeletal survey were recognized fracture in 37% and child abuse features (bruising, burns, sexual abuse) in 19%.
  • 76 (10.8%) of children had positive results.
  • The rate of positive skeletal survey results was higher in children younger than 6 months vs children older than 6 months (16.4% vs 6.8%).
  • Of children with positive results, 55% had a single fracture, 24% had 2 fractures, and 21% had 3 or more fractures.
  • The most common location of fractures was the ribs.
  • Of 62 children with data on fracture age, 49 (79%) had at least 1 healing fracture (35 with healing fracture only and 14 with both acute and healing fractures), and 13 (21%) had only acute fractures.
  • Children with positive vs negative skeletal survey results had a lower median age (4 vs 8 months; P = .001)
  • Rates of positive survey results were higher in children who presented for an apparent life-threatening event or apnea (12 [18.2%] of 66; P = .05) or seizure (6 [33%] of 18; P = .02) vs other reasons.
  • These rates were higher if the reason for the survey was suspected abusive head trauma vs other reasons (20 [23%] of 88 vs 56 [9.1%] of 615).
  • Children with recognized fractures diagnosed before the skeletal survey were not more likely to have positive results.
  • Physical abuse was diagnosed in 58 of 76 children with positive skeletal survey results.
  • Of these 76 children with positive skeletal survey results, the results directly influenced the decision to diagnose abuse in 38 (50%). Of the remaining 38 children, the diagnosis would have been made even with negative results in 18 children, or abuse was not diagnosed in 20 children.
  • Study limitations were retrospective design and possible physician bias in ordering the skeletal survey.

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