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Selective Skeletal Surveys for Infants With Skull Fractures: Examining the Rates of Return to Medical Care for
Michelle M Dominguez1, Jessica L Moore2, Megan Cook2
1From the Division of Pediatrics, Department of Pediatrics, The Alpert Medical School of Brown University.
Insights
Skull fractures in infants may not always require a skeletal survey. Consulting a child abuse pediatrician (CAP) and thorough evaluation are key first steps in assessing potential physical abuse.
Area of Science:
- Pediatrics
- Forensic Medicine
- Child Abuse Research
Background:
- Skull fractures in infants are a significant concern for potential non-accidental trauma.
- Evaluating the necessity of diagnostic imaging like skeletal surveys is crucial for timely intervention.
Observation:
- A retrospective review of 366 infants under 12 months with skull fractures was conducted.
- Consultation with a child abuse pediatrician (CAP) occurred in 74% of cases.
- Skeletal surveys were performed in 20.8% of infants with skull fractures.
Findings:
- Younger age, lack of clear history, co-occurring injuries, and social risk factors were associated with skeletal survey acquisition.
- Only 1.6% of infants re-presented with concerns for physical abuse by age 3.
- Five of these six infants had not received a skeletal survey at initial presentation.
Implications:
- A skeletal survey may not be universally necessary for all infant skull fractures.
- Comprehensive history, physical examination, and CAP consultation are vital initial steps.
- This approach aids in effectively evaluating infants for physical abuse following a skull fracture.
Objectives:
This study aimed to describe which infants with a skull fracture (1) receive a child abuse pediatrician (CAP) consultation, (2) receive a skeletal survey, and (3) re-present to medical care before age 3 years with concerns for physical abuse.
Methods:
We conducted a retrospective chart review of infants younger than 12 months who presented to the emergency department between January 1, 2005, and December 30, 2015, with a skull fracture. Medical records were reviewed for the skull fracture presentation and for all future medical evaluations at the same institution with concerns for physical abuse until 3 years of age.
Results:
Of 366 infants with a skull fracture, a CAP was contacted for 272 (74%) and 76 (20.8%) infants who received a skeletal survey. Factors associated with skeletal survey acquisition included younger age (<6 months), no history to explain the skull fracture, other injuries on examination, and social risk factors. Six children (1.6%) re-presented to medical care with concerns of physical abuse before age 3 years. Five of these infants did not have a skeletal survey at the time of their skull fracture, and 1 was likely a case of missed physical abuse at the time of the skull fracture.
Discussion:
Most skull fractures in infancy occur accidentally, and a skeletal survey may not be necessary for every infant. Obtaining a thorough history including social risk factors, performing a complete physical examination, and consulting with a CAP is an effective first step in the evaluation of physical abuse in infants with skull fractures.
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