Sensitivity of the Limited View Follow-up Skeletal Survey WHAT’S KNOWN ON THIS SUBJECT: A previous study suggested that spine and pelvis views may be omitted from the follow-up skeletal survey protocol for suspected child abuse, when these views are normal on the initial skeletal survey, without limiting the sensitivity of the study. WHAT THIS STUDY ADDS: This multicenter study provides estimates of the risk of missing occult fractures in the evaluation of suspected child abuse with omission of spine and pelvis views from the follow-up skeletal survey protocol. Results may be used to update practice recommendations. abstract BACKGROUND AND OBJECTIVE: Reducing radiation exposure to mini- mize risk has been emphasized in recent years. In child abuse, the risk of missing occult injuries is often believed to outweigh radiation risk associated with skeletal surveys. Our hypothesis was that there would be no clinically significant difference in results from a limited view, follow-up skeletal survey (SS2) protocol, which omits spine and pelvis views unless these views have findings on the initial skeletal survey (SS1), compared with a traditional SS2 protocol for radiographic evaluation of suspected physical abuse. METHODS: This study was a retrospective record review involving 5 child protection teams. Consultations for suspected physical abuse were reviewed to identify subjects ,24 months of age who had an SS1 and a traditional SS2. The results of these studies were compared to identify subjects in which newly identified spine and pelvis frac- tures (fractures seen only on SS2 and not on SS1) would have been missed by using a limited view SS2 protocol. RESULTS: We identified 534 study subjects. Five subjects had newly identified spine fractures, and no subjects had newly identified pelvis fractures on traditional SS2 studies. Only 1 subject with a newly iden- tified spine fracture would have been missed with the limited view SS2 protocol used in this study (0.2% [95% confidence interval: ,0.005– 1.0]). None of the newly identified fractures changed the abuse- related diagnosis. CONCLUSIONS: We found no clinically significant difference in the results of a limited view SS2 protocol versus a traditional SS2 protocol for ra- diographic evaluation of suspected abuse. Pediatrics 2014;134:242–248 AUTHORS: Karen Kirhofer Hansen, MD, a Brooks R. Keeshin, MD, b Emalee Flaherty, MD, c Alice Newton, MD, d Sarah Passmore, MD, e Jeffrey Prince, MD, f and Kristine A. Campbell, MD, MSc a a Primary Children’ s Hospital, University of Utah, Salt Lake City, Utah; b Cincinnati Children’ s Hospital Medical Center, Cincinnati, Ohio; c Ann and Robert H. Lurie Children’ s Hospital of Chicago, Northwestern University, Chicago, Illinois; d Children’ s Hospital Boston, Harvard University, Boston, Massachusetts; e The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and f Intermountain Pediatric Imaging, Department of Medical Imaging, Primary Children’ s Hospital, Salt Lake City, Utah KEY WORDS abuse, fractures, radiation, skeletal survey ABBREVIATIONS AAP—American Academy of Pediatrics ACR—American College of Radiology ALARA—as low as reasonably achievable CI—confidence interval CT—computed tomography IQR—interquartile range SS1—initial skeletal survey SS2—follow-up skeletal survey Dr Hansen participated in the initial conceptualization and design of the study, planned and participated in data collection, participated in analysis and interpretation of data, drafted the initial manuscript, reviewed and revised the initial manuscript, and finalized the final manuscript as submitted; Dr Keeshin participated in the initial conceptualization and design of the study, planned data collection, designed the data collection instrument and participated in data collection, participated in analysis and interpretation of data, and assisted with the drafting of and critical revision of the initial manuscript; Drs Flaherty, Newton, Passmore, and Prince participated in the concept and design of the study, collected data, and assisted with critical revision of the initial manuscript; and Dr Campbell directed the initial conceptualization and design of the study, directed the analysis and interpreted the data, and assisted with the drafting of and critical revision of the initial manuscript. All authors approved the final manuscript as submitted. www.pediatrics.org/cgi/doi/10.1542/peds.2013-4024 doi:10.1542/peds.2013-4024 Accepted for publication Apr 25, 2014 Address correspondence to Karen Kirhofer Hansen, MD, Center for Safe and Healthy Families, 675 East 500 South, Suite 300, Salt Lake City, UT 84102. E-mail: karen.hansen@imail.org PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2014 by the American Academy of Pediatrics (Continued on last page) 242 HANSEN et al by guest on March 21, 2017 Downloaded from