Introduction: Child abuse is relatively common and affects between 4-16% of all children. Fractures are the second most common non-accidental injuries, after cutaneous lesions. When abuse is suspected in a less than 24 months old child, specific thorough investigations are essential. They include a clinical examination, laboratory tests, a fundoscopy, a skeletal survey (SS), cerebro-spinal images (CT-scan or MRI) as well as other specific imaging studies depending on the case. The aims of the study were to perform a quantitative and qualitative analysis of skeletal survey performed in children at the University Hospital of Lausanne (CHUV) over a period of 10 years.
Methods: All Patients included in the study were less than 24 months old and had at least one SS performed at the CHUV between 1st January 2009 and 31st December 2018. Case identification was performed by searching the internal PACS system using specific inclusion criteria such as age and the number of radiographs performed. Data collection included demographics, reason for consultation, fractures identified before and after SS, clinical and para-clinical investigations and final Child Abuse and Neglect (CAN) Team evaluation. SS were reviewed and assessed according to the indication, number and quality of radiographs performed. Follow-up imaging studies were identified and reviewed in the same manner. International guidelines for SS were used as gold standard (the Royal College of Radiology/Royal College of Paediatrics and Child Health (RCP/RCPCH) and the European Society of Paediatric Radiology (ESPR) guidelines). Descriptive statistics were used. All data was anonymised.
Results: A total of 53 children with a mean age of 7±4,7 months (median 6 months) were identified. 41,5% (n=22) had a significant past medical history, most commonly prematurity. Reason for consultation included skin lesion in 12 (22,6%), fall in 10 (18,9%) or restriction of limb use in 8 (15,1% ; n=8). Referral occurred in 47,2% of the cases (n = 25). Fundoscopy was performed in 79,2% (n=42), cerebral CT-scan in 25,5% (n=14), cerebral MRI in 46,8% (n=30), cervical MRI in 5,9% (n=5), abdominal ultrasound in 3,8% (n=2) and bone scintigraphy in 7,5% (n=4). Outcome was fatal for two infants (3,8%). 33 patients (62,3%) were identified by the CAN team as suspicious cases of abuse and were reported to the justice. The number of SS realised at the CHUV increased over the 10 years. Occult fractures were identified in 34% of the SS (n=18). The most common fracture was a long bone fracture, as found in 41,7% (n=35) of the cases. Fractures affected the ribs in 25% (n=21), skull in 11,9% (n=10) and were classical metaphyseal lesion (CML) in 5,9% (n=5) of the cases. Follow-up studies were carried out in 20,8% (n=11), with a mean time of 18,5 ± 8,8 days (median 22 days) from the initial SS.
Discussion and conclusion: The children mean and median ages were similar to what was found in other studies. The most common reason for consultation was a skin lesion. Two thirds of the SS (n=33) were performed in child abuse cases, identifying one or more fractures in half of the cases (n=16). Incomplete follow-up SS were performed in 11 cases. With regards to the other investigations performed, fundoscopy was realised in 85%. There were more cerebral MRI than CT and neck MRIs were rarely performed. International guidelines for SS were never fully respected.. Strict compliance to guidelines is recommended when performing SS in order to offer appropriate care for children suspected of abuse. Special awareness for possible abuse should be raised for children less than 6 months old with a fracture who presented to the emergency department with a skin lesion and a history of prematurity