Follow-up Skeletal Surveys After Suspected Pediatric Non-accidental Trauma: A Systematic Review

Background: Recently, pediatric non-accidental trauma (NAT) has seen a revival in the literature, garnering the attention of pediatricians around the world. Currently, skeletal surveys (SS) are the standard of care in children under 24 months of age with suspected NAT. A follow-up skeletal survey (FUSS) is recommended approximately 2 weeks after SS to identify occult or date previous injuries. The aim of the current study is to perform a systematic review of current literature to 1) assess the utility of FUSS in detecting suspected NAT and, 2) evaluate the risks and benefits of limited view FUSS.

Methods: PubMed, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials and Embase were searched on January 19th 2021 for journal articles targeting the use of FUSS following suspected NAT in the pediatric population. Results were then screened for relevance by two independent reviewers based on established criteria. A third independent reviewer was consulted in cases of disagreement. Articles dating before January 1st 2000 were excluded. Included search results were evaluated using the quality appraisal tool specific to validity studies (QAVALS).

Results: Out of 3,287 de-duplicated search results initially attained, nine met our criteria. Of these, six pertained specifically to the utility of FUSS in the NAT setting and 3 pertained to minimizing radiological exposure during FUSS. Rate of new information identified on FUSS varied from 6-46%. Studies pertaining to radiologic exposure called into question the utility of lateral spine, AP pelvis, hands, and feet views.

Conclusion: The literature continues to support the use of FUSS for the management of suspected NAT in children under two years of age. Additionally, these results suggest that the limited 11, 13, or 15-view FUSS protocols reduce radiographic exposure in children without drastically increasing the number of subjects missed. Although its clinical value is apparent, differences in institutional FUSS imaging protocols and authors’ definitions of “new information” preclude definitive conclusions to be drawn quantifying the potential benefit of FUSS. Standardization of practice through organizations such as the AAP, ACR, WTA, and PTS, along with quality improvement initiatives from individual institutions to maximize FUSS adherence, have the potential expand the use of FUSS as a diagnostic tool in pediatric NAT and serve to better protect the abused child.