Do skeletal surveys contribute to the diagnosis of abuse in asymptomatic children under 2 years of age with skull fractures?

Purpose: Skull fractures (SFs) occur in up to 20% of patients younger than 2 years after blunt trauma, and up to one-third are caused by physical abuse.We aimed to identify clinical predictors of the use of skeletal survey (SS) and diagnosis of non-cranial fractures (NCFs) on the SS in patients <24 months with neurologically asymptomatic SF, and to examine whether SS contributed to the diagnosis of abuse or neglect.Methods: We retrospectively reviewed medical records of patients <24 months with neurologically asymptomatic SF who presented to 1 of 2 tertiary hospitals in San Antonio, Texas, and were referred to the Division of Child Abuse, from December 2014 through May 2024.Data collected included age, ethnicity/race, fracture type, SS findings, trauma history, motor development, and abuse assessment.Multivariable logistic regression was performed to identify predictors associated with the use of SS or the diagnosis of NCFs.Results: Among a total of 304 patients whose median age was 8.4 months (interquartile range, 4.8-10.8),170 (55.9%) underwent SS.Negative predictors of SS use were the clinical practice by trauma surgeons (compared to that by pediatric emergency physicians: adjusted odds ratio, 0.42 [95% confidence interval, 0.25-0.72])and impact history (0.15 [0.04-0.53]),while positive predictors were the concern for abuse (46.80 [2.81-779.0])or neglect (6.05 [2.40-15.20]).Of the 170 patients who underwent SS, 13 (7.6%) had NCFs.Predictors of the NCFs were the complex SF (23.80 [1.87-302.0]),concern for abuse (21.20 [4.39-102.0]),and clinical practice by trauma surgeons (0.15 [0.03-0.85]).Overall, the SS contributed to the diagnosis of abuse or neglect in 11 patients. Conclusion:These results suggest that the decision to obtain SS in patients <24 months should focus on the history, including the development and examination for cutaneous findings.