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Published on: January 29, 2018
Skeletal surveys in infants with isolated skull fractures
Joanne N Wood1, Cindy W Christian, Cynthia M Adams
1Department of General Pediatrics and Safe Place: The Center for Child Protection and Health, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA. woodjo@email.chop.edu
Insights
Skeletal surveys for infant skull fractures rarely detect additional injuries. These surveys and child protective services reports were more common in uninsured infants with concerning clinical findings.
Area of Science:
- Pediatric Radiology
- Child Abuse Pediatrics
- Forensic Radiology
Background:
- Skull fractures in infants can be challenging to diagnose and manage.
- Determining the etiology of infant skull fractures is crucial for appropriate medical and legal interventions.
- Child protective services (CPS) involvement is a critical consideration in cases of suspected non-accidental trauma.
Purpose of the Study:
- To evaluate the diagnostic utility of skeletal surveys in infants with isolated skull fractures.
- To identify factors associated with the use of skeletal surveys in this population.
- To determine factors influencing referral to child protective services for infants with skull fractures.
Main Methods:
- Retrospective chart review of infants with isolated, non-motor vehicle-related skull fractures (1997-2006).
- Logistic regression analysis to assess associations between demographic/clinical factors and skeletal survey use/CPS reports.
- Evaluation of fracture type (simple vs. complex) and suspicious clinical findings.
Main Results:
- 31% of infants had clinical findings suspicious for abuse; 42% had complex fractures.
- Skeletal surveys were performed in 41% of cases, detecting additional fractures in only 1.4%.
- Medicaid-eligible/uninsured infants were more likely to undergo skeletal surveys and CPS reporting, especially with complex fractures or suspicious findings.
Conclusions:
- Skeletal surveys are frequently utilized for infant skull fractures but offer limited additional diagnostic value beyond clinical assessment.
- Clinical findings suggestive of abuse and fracture complexity are key drivers for skeletal survey use and CPS referrals.
- The study highlights potential disparities in healthcare utilization and reporting based on insurance status.
Objective:
The goal was to describe the utility of skeletal surveys and factors associated with both skeletal survey use and referral to child protective services for infants with skull fractures in the absence of significant intracranial injury.
Methods:
A retrospective chart review was performed for infants who were evaluated at a tertiary children's hospital because of an isolated, non-motor vehicle-related, skull fracture between 1997 and 2006. Logistic regression analyses were used to test for associations of demographic factors, clinical findings that raised suspicion for abuse (absence of trauma history, changing history, delay in care, previous child protective services involvement, and other cutaneous injuries), and fracture type (simple versus complex) with the primary outcomes of skeletal survey use and reports to child protective services.
Results:
Among the 341 infants in the study, 31% had clinical findings that raised suspicion for abuse and 42% had complex skull fractures. Skeletal surveys were obtained for 141 infants (41%) and detected additional fractures for only 2 (1.4%) of those 141 infants. Child protective services reports were made for 52 (15%) of the 341 children. Both infants with positive skeletal survey findings had other clinical findings that raised suspicion for abuse, and they were among those reported. With controlling for race and age, Medicaid-eligible/uninsured infants were more likely than privately insured infants to receive skeletal surveys and child protective services reports in the presence of a complex skull fracture or clinical findings that raised suspicion for abuse.
Conclusion:
Skeletal surveys were ordered frequently for infants with isolated skull fractures, but they rarely added additional information, beyond the history and physical findings, to support a report to child protective services.
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