Is a skeletal survey necessary for older children with suspected underlying bone conditions, such as child abuse or metabolic bone diseases?

Skeletal Survey Use in Older Children

Skeletal surveys are generally not necessary for children over 5 years of age with suspected abuse, but may be appropriate for children ages 2-5 years when clinical suspicion is high based on specific red flags. 1

Age-Based Recommendations

Children Under 2 Years

• Skeletal survey is mandatory for all children younger than 2 years with fractures suspicious for child abuse 1, 2
• The yield is highest in infants, with approximately 10% of skeletal surveys identifying additional fractures 1
• 80% of abused children with fractures are under 18 months of age, making this the critical age group 2

Children Ages 2-5 Years

• Skeletal surveys may be appropriate depending on clinical suspicion of abuse 1, 2
• The decision should be guided by specific clinical indicators rather than age alone 1
• This represents a gray zone where clinical judgment is essential 2

Children Over 5 Years

• Skeletal surveys are typically not indicated in this age group 1
• If specific clinical findings indicate an injury at a particular site, targeted imaging of that area should be obtained regardless of age 1

Clinical Indicators That Support Skeletal Survey in Older Children (Ages 2-5)

The following red flags should lower your threshold for obtaining a skeletal survey even in older children:

• High-specificity fractures for abuse: posterior rib fractures, classic metaphyseal lesions, epiphyseal separation injuries 1, 2
• Multiple fractures or fractures of different ages 1
• Fracture mechanism inconsistent with injury severity or type 1
• Inconsistent or changing histories from caregivers 1
• Delay in seeking care for the injury 1
• Other injuries suspicious for abuse (bruising in unusual locations, other trauma) 1

Important Caveats

Differential Diagnosis Considerations

• Always consider metabolic bone diseases that can mimic abuse, including osteogenesis imperfecta, Ehlers-Danlos syndrome, hypophosphatemic rickets, and hypophosphatasia 3, 4
• Look for clinical clues: blue sclerae (OI), sparse kinky hair (Menkes disease), dentinogenesis imperfecta, family history of multiple fractures or early hearing loss 1
• Laboratory evaluation should include calcium, phosphorus, alkaline phosphatase, and consider PTH and 25-hydroxyvitamin D if osteopenia is present 1

Follow-Up Protocol

• If the initial skeletal survey is abnormal or equivocal, or if abuse is strongly suspected clinically, obtain a repeat skeletal survey at 2-3 weeks 1, 2, 5
• The follow-up examination detects healing fractures in 9-12% of cases after an initially negative survey 2, 6
• Follow-up surveys increase the total number of detected fractures by 27% and provide crucial information about fracture age 5

Technical Requirements

• The complete skeletal survey must include 21 images with specific views of all body regions 1, 2
• Oblique rib views are essential as rib fractures may be the only skeletal manifestation of abuse in 30% of cases 2
• Poor quality images or failure to follow protocol guidelines result in missed fractures 1

Practical Algorithm for Older Children

For children ages 2-5 years with fractures:

1. Assess for high-risk features (multiple fractures, high-specificity fractures, inconsistent history, delay in care)
2. If ANY high-risk features present → obtain full skeletal survey 1, 2
3. If low suspicion but fracture pattern unusual → consider targeted imaging of symptomatic areas 1
4. Always evaluate siblings and household contacts under 2 years, as 37% of households have all siblings affected 7

For children over 5 years:

1. Skeletal survey generally not indicated 1
2. Obtain targeted imaging only for specific symptomatic sites 1
3. Focus on other modalities: head CT if neurologic concerns, abdominal imaging if indicated 1, 7