Radiology : Extremity Fractures and Skeletal Survey

Diaphyseal Fractures

Diaphyseal fractures are common accidental injuries. No type of diaphyseal fracture is diagnostic of abuse. For more information, see Common Types of Diaphyseal Fractures Seen in Childhood [NEED LINK]. Extremity X-rays are usually ordered based on physical examination findings, namely pain or abnormal structural/functional findings. In young patients, where localization of pain and tenderness is not possible, skeletal surveys help to identify occult fractures. In patients with open growth plates, comparison films of the non-affected side may be necessary for diagnosis. This is especially important if the joints are being evaluated.

Skeletal Survey

When abuse is suspected, a skeletal survey is used to identify evidence of previous or acute injuries. It consists of dedicated images of every anatomic region. It includes anteroposterior and lateral images of the axial skeleton and frontal projections of each extremity. Hospital protocols should be reviewed regarding trauma informed methods for stabilizing the young child during these examinations and use of the lowest amount of radiation needed per FDA Guidance, see: https://www.itnonline.com/article/fda-releases-new-guidance-childrens-x-ray-exams.

A skeletal survey should be performed for all children younger than 2 years with potential AHT (Meyer et al 2011) or older children where the medical provider assessment of pain or tenderness is challenging due to the patient’s acute condition, ability to communicate to the provider, and/or motor development that is more consistent with a younger age child. For children older than 2 years, extremity fractures may be more identifiable, without the need for a full survey, due to findings of tenderness, swelling, gait abnormalities and refusal to bear weight. See below and CHAMP Practice Recommendations for Skeletal Surveys (2021).

A follow-up skeletal survey, without skull films, is usually recommended at 10-14 days because of the lag time for healing bone injuries (Ashraf et al 2022). This is particularly true for rib fractures because there is significant displacement of fractures is uncommon, and the fracture is less evident until there is callus formation. In some cases, a complete repeat physical examination is appropriate, with a limited follow-up skeletal survey examination.

Complete Skeletal Survey Imaging

A single radiograph, sometimes called a “babygram” of the entire infant is not sufficient and does not provide enough detail for evaluation and should not be performed. Images described below are recommended.

The American College of Radiology has published the ACR Appropriateness Criteria® Suspected Physical Abuse–Child: https://acsearch.acr.org/docs/69443/Narrative.

Cervical Spine Concerns

The patient should remain in c-spine immobilization until the cervical spine has been appropriately cleared. Imaging of the remainder of the spine is determined by the index of suspicion, mechanism of injury, and results of the initial examination. For infants with suspected AHT, MRI or fast MRI of the spine should be considered to assess for ligamentous injuries or spinal subdural hemorrhage. Note that lack of c-spine findings does not rule out or exclude the possibility of abusive head trauma (Piteau et al 2012 and Narang et al 2020). For more information, see the section on Thoracic Trauma Imaging below.

Specificity of Fractures for Abuse

Radiological examinations can be utilized to evaluate whether findings have a significant association with abuse. The table below identifies which injuries have a high specificity for abuse.

The presence or absence of bruising over the area of fracture is not predictive of abuse and is not useful in the differentiation between abusive and non-abusive fracture injuries (Valvano et al 2009).