603 - The Use of Skeletal Surveys of Child Abuse Pediatricians: Age is Key

Poster Number: 603
Publication Number: 603.103

Caitlin McNamara, UPMC Childrens Hospital of Pittsburgh, Pittsburgh, PA, United States; Emily Heineman, UPMC Childrens Hospital of Pittsburgh, Pittsburgh, PA, United States; Adelaide Eichman, University of Pittsburgh, Pittsburgh, PA, United States; Jennifer Wolford, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States; Matthew E. Valente, UPMC Childrens Hospital of Pittsburgh, Pittsburgh, PA, United States; Maria C. Antonucci, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States; Carmen M. Coombs, chp, Pittsburgh, PA, United States; Hannah B. Sahud, UPP0-Univeristy of Pittsburgh Physicians, Pittsburgh, PA, United States; Rachel P. Berger, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States; Jennifer S. Clarke, My. Sinai School of Medicine and NYC H+H Elmhurst Hospital, Jamaica, NY, United States

Background: Skeletal surveys (SS) are mandatory in the evaluation of physical abuse < 24 months old and at providers’ discretion in older children. Previous single-site data suggest that it is rare for older children to have occult fractures. Identifying the subset of older children who would benefit from SS would decrease unnecessary radiation exposure.

Objective: Our objective was to examine rates of SS and occult fractures in older children as well as variables associated with occult fractures in this age group.

Design/Methods: Children < 120 months old were identified in CAPNET, a multicenter child abuse research network from February 2021 to April 2022.  Non-parametric statistical tests were conducted to assess the rates of obtained SS and the proportion showing occult fractures stratified by age.  Patients >24 months old who had received SS during an evaluation by a child abuse pediatrician   were then included to examine characteristics associated with occult fractures.  SS were defined as having occult fractures if a fracture not previously identified was recognized.

Results: SS were obtained in 66% (2438/3722) of children; 13% (323/2438) showed an occult fracture. Ninety-nine percent of children < 12-month-old had a SS with deceased proportions in each older age group; only 3% of patients 60-120 months old had a SS. The proportion of SS with occult fractures was significantly different between the < 24 month and > 24-month-old age groups [13% (277/2204) vs 2.8% (43/1518)].  The absolute number of SS with occult fractures in older children was low (e.g., 4 in children 60-120 months old). Older children with occult fractures (n=43) were more likely to have fractures of a long bone (n=22), hand/foot (n=11), spine (n=7), or rib (n=6) than patients with a fracture but a negative SS (p < 0.001 for each). Of older patients with a SS, 41% (127/308) had a high concern for abuse (5-7 on a scale of 7 for abuse concern); 21% (27/127) had an occult fracture.  In children with low concern for abuse, 9% (16/181) had an occult fracture (p < 0.003). The proportion of SS with an occult fracture in older children with vs without comorbidities was similar [8% (7/83) vs 16% (36/225) p > 0.05].

Conclusion(s):

Child abuse pediatricians almost universally complete SS in children < 24 months old with concerns for physical abuse consistent with AAP recommendations. The proportion of patients with SS decrease significantly with increasing age as does the rate of occult fractures. Abuse is more frequently diagnosed in patients > 24 months old with occult fractures compared with those without.