Development of guidelines for skeletal survey in young children with fractures

Abstract

Objective: To develop guidelines for performing initial skeletal survey (SS) in children <24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties.

Methods: Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children <24 months old. After discussion on the initial ratings, panelists re-rated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary.

Results: Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children <12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type.

Conclusions: A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse.

Keywords: child abuse; child maltreatment; fracture; skeletal survey; trauma.

FIGURE 1

Procedure of the Rand/UCLA Appropriateness Method.

FIGURE 2

Summary of Key Skeletal Survey Guidelines. The guidelines synthesize the panelists’ responses from Tables 1, 2, 3, and 4. They apply to children who do not have a verifiable mechanism of accidental trauma (ie, MVC or fall in public place), do not have underlying bone fragility, such as osteogenesis imperfecta, and who do not have a clear history of birth trauma that accounts for the injury.