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Assessing the use of follow-up skeletal surveys in children with suspected physical abuse

BACKGROUND Child physical abuse is an important cause of morbidity and mortality in young children. The skeletal survey (SS) is considered a mandatory part of the evaluation for suspected physical abuse in young children. Literature suggests that a follow-up SS performed 10 to 21 days after the initial SS can provide important additional information, but previous studies evaluating the follow-up SS have been small and included very selective patient populations. METHODS A retrospective descriptive study of a consecutive sample of children who underwent an initial SS and a follow-up SS at a single children’s hospital during a 7-year period. Data on demographics, clinical presentation, results, and effect of the follow-up SS on clinical diagnosis were collected. RESULTS Of the 1470 children who underwent an initial SS, 11% (169 of 1470 children) also underwent a follow-up SS. The mean age of the children who underwent both an initial SS and a follow-up SS was 5.8 months. Fourteen percent of the follow-up SS identified previously unrecognized fractures; all of which were healing. There were eight children in whom the information obtained from the follow-up SS resulted in a diagnosis of definite physical abuse; all eight children were younger than 12 months, and in six of these cases, the initial SS did not demonstrate any fractures. CONCLUSION Only a small proportion of children who undergo an initial SS also undergo a follow-up SS. The relatively high proportion of follow-up SS that demonstrated previously unrecognized fracture(s), the young age of children undergoing the follow-up SS, and the high morbidity and mortality of unrecognized/missed child physical abuse in this age group suggest that the follow-up SS should be a routine part of the evaluation of child physical abuse. LEVEL OF EVIDENCE III, observational study.