In general, the panelists agreed that SS should be performed:
- when a fracture results from abuse, domestic violence, or being hit by a toy or other object;
- in cases with rib fractures and in children without a history of fracture from trauma, "except in the ambulatory child ≥12 months old with a toddler fracture or buckle fracture of the radius/ulna or tibia/fibula"; and
- almost universally in children younger than 12 months.
The panelists also agreed that SS should not be performed in 2 specific cases if no abuse is suspected:
- "Distal spiral fracture of the tibia/fibula in a child 12–23 months old with a history of fall while running/walking," or
- "Distal radial/ulna buckle feature in an ambulatory child 12–23 months old with a history of a fall onto an outstretched hand."
STUDY AND GUIDELINE HIGHLIGHTS
- Researchers applied the Rand/University of California, Los Angeles, Appropriateness Method tool to a panel of expert physicians. This method has been used to evaluate the appropriateness of clinical recommendations with high predictive validity.
- After a literature review for articles evaluating the use of SS, all of which were published between 1990 and 2011, researchers developed 240 clinical scenarios based around different presentations of fracture and suspected physical abuse. The expert committee first determined whether SS would be appropriate for the particular scenario. Beyond appropriateness, they then judged whether SS would also be necessary.
- All case scenarios were free of other medical or trauma complications that might otherwise influence the risk for fracture.
- Disagreements regarding the appropriateness or necessity of SS for particular case scenarios were resolved during conference calls with the expert panel, although such disagreements were rare.
- Overall, SS was thought to be appropriate in 191 (79.6%) of the 240 cases, inappropriate in 2 cases (0.8%), and of unclear appropriateness in 47 cases (19.6%). There was disagreement in only 7 case scenarios, and the greatest disagreement about application of SS was encountered in cases of children between the ages of 12 and 23 months with nonmetaphyseal fractures after a history of falling.
- SS was judged to be necessary in 91.6% of cases in which it was appropriate to use.
- Specifically, SS was found to be necessary for children between the ages of 0 and 23 months with fractures clearly related to abuse or with other signs of abuse, such as bruises or burns.
- A delay of seeking care for more than 24 hours after any fracture in a child younger than 12 months was also considered a certain indication for SS. Among children between 12 and 24 months of age, this indication should only stand for painful fractures or obvious physical findings.
- Children younger than 12 months with nearly any long bone fracture should undergo SS, with the exception of children with radius/ulna buckle fracture or toddler fracture while cruising or walking between 9 and 11 months of age. This same fracture with a history of falling onto an outstretched hand should disqualify children between ages 12 and 23 months from SS, as does tibia/fibula toddler fracture with a history of fall while walking.
- SS is also necessary for all cases of a classical metaphyseal lesion and for fractures resulting from being hit with a toy or other object.
- All children younger than 12 months with skull fracture should be assessed with SS, with the exception of linear, unilateral skull fractures attributed to a fall from a height or a caregiver falling on the infant. Complex or ping-pong skull fractures mandate SS regardless of age.
- Rib fractures are an indication for SS for all children between the ages of 0 and 23 months.
- SS should be performed among children younger than 12 months with clavicle fracture. It is unnecessary among children between the ages of 12 and 23 months with a history of fall.
- Among children younger than 12 months of age hospitalized for fracture in the United States, one quarter will be diagnosed with physical abuse. Rates of physical abuse are lower among children between the ages of 12 and 23 months. Physical abuse is underdiagnosed among white, higher-income families and overdiagnosed among ethnic minority and lower-income families.
- The current study suggests that SS is necessary for the majority of cases of fracture among children younger than 24 months. Exceptions include linear skull fractures after a history of fall and clavicle, radius/ulna buckle fracture, and tibia/fibula toddler fractures related to falling among children between the ages of 12 and 23 months.
Child Abuse