Assessing the Use of Follow-up Skeletal Surveys in Children with Suspected Physical Abuse

Background: A follow-up SS (FSS) can provide additional clinical data in a subset of children that undergo an initial skeletal survey (ISS) for the evaluation of physical abuse. Three studies suggested that 33-57% of FSS identify additional fractures, but the study populations were small and highly selective. Objective: To assess a consecutive study sample of children who underwent an ISS and FSS, to evaluate the results of the ISS and FSS, and to calculate the proportion in whom clinical diagnosis depended on the FSS results. Methods: This was a retrospective, descriptive study of children who had an ISS and FSS at Children's Hospital of Pittsburgh of UPMC from 4/1/02 to 3/31/09. Data were collected about demographics, reason for and results of ISS and FSS, the interval in days between ISS and FSS, and whether the FSS affected clinical diagnosis.Results: During the 7-yr study period, 1470 children underwent an ISS. Eleven percent (169/1470) of these children also underwent a FSS. These 169 children made up the subjects of the study. The FSS identified 39 fractures in 16% (27/169) of the study subjects. All 39 fractures were rib, metaphyseal or metacarpal. The identification of new fractures on FSS led a definite diagnosis of abuse in 7.6% (7/92) of the subjects who did not have a previous diagnosis. These 7 subjects were all less than a year of age. The ISS identified no fractures in 43% (3/7) of these subjects. A total of 29 fractures that were felt to be equivocal of ISS were confirmed as normal variants on FSS. Conclusions: This is the largest study to evaluate the use of FSS. The proportion of subjects with additional fractures identified on FSS was lower than in previous studies. The FSS made a definite diagnosis of abuse in ~8% of subjects. A large number of equivocal fractures on ISS were felt to be normal variants on FSS. Future studies will compare children who only receive an ISS with those who receive an ISS and FSS to identify characteristics that, when present in a child undergoing an ISS, also warrant a FSS