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G97(P) Follow-up skeletal surveys in safeguarding investigations – what is the evidence?

Background Radiological investigation is crucial in expediting safeguarding concerns, as it lends great weight to healthcare professionals’ suspicions of abuse. The United Kingdom’s Royal College of Radiologists recommends compulsory skeletal surveys in all children under two years. Follow-up imaging is recommended in all cases, with the justification that some fractures may only appear radiologically when healing. Aim This literature review aims to explore the evidence behind follow-up skeletal surveys, with a view to evaluating their utility and overall impact on child protection outcomes. Methods This literature review was conducted using all research papers with the keywords ‘safeguarding’, ‘children’, and ‘skeletal survey’. This generated 26 articles containing information relevant to the review’s aims. Results Ten articles supported the use of repeat skeletal surveys. The repeat skeletal survey in a retrospective study on 1470 children by Singh et al identified new fractures in 14% of cases, which were not detected upon initial survey. Similar studies by Kleinman et al and Zimmerman et al identified detection rates of 29% and 46% respectively. Sanchez et al found that 17% of rib fractures were only detected on follow-up. This latter study also highlighted that repeat surveys were particularly important in dating fractures near metaphyseal sites, where dating from initial survey often proves difficult. However, a study by Doherty et al concluded that repeat surveys should only be performed if clinically indicated. Conclusion Overall, there is existing evidence for the use of repeat imaging. Detection of fractures on repeat survey will certainly have significant impact on safeguarding investigations. However, consensus is lacking as to whether repeat surveys should involve the whole body or be limited. Given the increased detection of rib and metaphyseal fractures on repeat skeletal surveys, it may be sensible to suggest that repeat surveys be limited to chest views. These study findings will be important in the ongoing evaluation of a child’s best interests, balancing the importance of a full safeguarding investigation against the need for repeated and cumulative radiation exposure.