Diagnostic Accuracy of Whole-body Magnetic Resonance Imaging versus Skeletal Survey in Suspected Child Physical Abuse: A Systematic Review of Comparative Studies

Abstract Skeletal survey (SS) is the reference standard for imaging in suspected child physical abuse but may miss subtle or extra-skeletal injuries and entails ionizing radiation. Whole-body magnetic resonance imaging (WBMRI) is a radiation-free alternative that might complement SS by detecting soft tissue and visceral injuries. The objective of this review is to compare the diagnostic performance and clinical utility of WBMRI versus SS in infants and young children with suspected abuse. Following Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020, we systematically searched PubMed (MEDLINE), Embase, Scopus, and the Cochrane Library from inception until June 2023, screened reference lists, and applied predefined inclusion criteria requiring in-patient comparison of WBMRI and SS with reporting of diagnostic yield/accuracy. Two reviewers independently screened, extracted data, and assessed study quality with Quality Assessment of Diagnostic Accuracy Studies 2. Owing to the small number and heterogeneity of eligible studies, we conducted a narrative synthesis. Two studies met the inclusion criteria: a single-center series of 21 infants and a multicenter observational study (PEDIMA) of 170 children. Across studies, WBMRI detected additional soft-tissue and visceral injuries (and some skeletal lesions) that SS missed, enhancing forensic documentation. However, SS remained superior in the detection of posterior rib, metaphyseal fractures, and other small cortical injuries. Both studies were of good methodological quality, although heterogeneity in protocols and limited blinding could introduce the bias. Meta-analysis was not feasible. Overall, in suspected child physical abuse, WBMRI adds diagnostic value to SS but does not replace it. A combined imaging strategy maximizes diagnostic yield – balancing SS’s fracture sensitivity with WBMRI’s broader soft-tissue/visceral reach – while avoiding unnecessary radiation exposure. Standardized WBMRI protocols, multicenter validation, and cost-effectiveness analyses are needed to define optimal deployment in the clinical and forensic pathways.