Guidelines prompt skeletal surveys

When should a young child’s fracture raise suspicion for abuse and prompt an order for a skeletal survey (SS), a series of about 20 radiographs? To answer this question, a multispecialty panel of 13 experts from key pediatric specialties, including child abuse, emergency medicine, trauma, radiology, and orthopedics, applied evidence from a literature review along with their own expertise in rating the appropriateness of performing an SS in hundreds of clinical scenarios. Of 240 scenarios, winnowed down from an initial 525, panelists agreed that SS was “appropriate” for 191, and in 175 of these 191 scenarios, appropriate but also “necessary.”

According to the guidelines, SS is necessary for children aged up to 23 months with fractures from abuse or domestic violence and for children with additional injuries unrelated to the fracture, such as bruises or burns. A delay of more than 24 hours in seeking care is an indication for SS in children aged up to 11 months, regardless of type of fracture or symptoms. In children aged 12 to 23 months, such a delay calls for an SS only if the fracture is associated with significant pain or physical findings.

Panelists determined that SS is necessary in children aged up to 11 months with long-bone fractures, excluding distal radius/ulna buckle fracture, or in fracture in children aged 9 to 11 months sustained during a fall while cruising or walking. In children aged 12 to 23 months, SS is necessary for a classic metaphyseal lesion and for fractures attributed to being hit by an object. Also, SS is necessary for skull fractures in children aged up to 11 months, except for infants aged 7 to 11 months with linear, unilateral skull fractures caused by falling.

In addition, SS was deemed necessary for children aged up to 23 months with rib fractures and appropriate for infants aged 11 to 21 days with acute fractures and infants aged younger than 30 days with healing fractures. Outside the neonatal period, SS is necessary in children aged younger than 24 months with acute fractures, except for those aged 12 to 23 months with history of a fall, according to guidelines (Wood JN, et al. Pediatrics. 2014;134[1]:45-53).

MS FREEDMAN is a freelance medical editor and writer in New Jersey. DR BURKE, section editor for Journal Club, is chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore, Maryland. The editors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.