Secondary skeletal surveys yield significant additional injuries: a retrospective review

Skeletal surveys play an important role in detecting occult injury in young children at risk from non-accidental injury. Current UK safeguarding guidance (2018) advises two skeletal surveys within 2 weeks in children under 2 years old. The first is a full survey (plus a CT head scan if under 1 year), alongside a secondary survey using selected views of the chest and long bones. Recent work suggested the rarity of detected injury did not justify the second exposure to ionised radiation. We wished to explore this important issue further.

Retrospective audit of all skeletal surveys in infants aged under 2 years against these guidelines between 1 January 2018 and 18 February 2025.

Children's Hospital for Wales.

Local children having radiological examinations for safeguarding evaluation. Out-of-area children were excluded.

Two skeletal surveys.

Adherence to guidelines in performing two surveys within 2 weeks, plus fracture rates found in first and second surveys.

Investigations performed in 186 children; 16 had only the primary survey and 2 were over 2 years leaving 168 for evaluation (90.3%). Secondary surveys carried out within 14 days in 161/168 (95.8%). Patients were classified in five presentation groups: bruise or skin lesion (n=106), fractures (n=43), domestic violence (n=15), fracture in sibling (n=2) and head injury (n=2). Skeletal surveys classified as normal, indeterminate or abnormal. 10/168 (6.0%) had fractures additional to the presenting injury on primary skeletal survey, 12/168 (7.1%) had additional fractures on secondary skeletal survey and 1/168 (0.6%) had a normal primary survey but fracture found solely on secondary survey.

A clinically important number of additional injuries and occasional new ones are found on second skeletal surveys. Our work supports the ongoing use of the current radiological investigation protocol with two surveys for this vulnerable group.