The Journal of the Arkansas Medical Society Med Journal Jan 2020 | Page 16

Scientific Article
by Liza Murray, MD; 1 Karen Farst, MD, MPH; 1 Pratik Doshi, MS; 2 R. Todd Maxson, MD 3
1
UAMS, Children at Risk; 2 UAMS, Center for Applied Research and Evaluation; 3 UAMS, Pediatric Surgery
A Skeletal Trauma
Pathway for Infants
Abstract
A
retrospective review of 276 infants that
was conducted to evaluate for skeletal
trauma with a clinical practice pathway
using a set of objective indicators for de-
cision making is presented here. Utilizing the clin-
ical practice pathway, 32 cases of additional frac-
tures were found (11.6%). Twenty two percent of
cases had a change in abuse suspicion following
completion of the pathway. Bruising at any site
was a positive predictor for abuse suspicion (OR
3.022; 95% CI 1.589-5.750; p = 0.0007). Type of in-
surance was not associated to final suspicion for
abuse. Use of an objective pathway may improve
detection of injuries and reduce bias when evalu-
ating infants with skeletal trauma.
Background
While abusive injury can occur in children
of any age, fractures from abusive events occur
most commonly in children < 18 months of age, 1
and the percent of fractures caused by abuse de-
clines markedly when children begin to walk. 2
History, physical examination findings, and the
presence of additional injuries are all important
factors in distinguishing abusive from non-abu-
sive fractures. 3,4 Skeletal surveys have been found
to identify additional fractures in over 10% of sus-
pected physical abuse cases, with an even high-
164 • The Journal of the Arkansas Medical Society
er rate in infants. 5 However, screening for occult
injuries varies by provider and institution 6 and
minority/disadvantaged children are screened
for abuse at disproportionately higher rates. 7
Algorithms utilizing objective factors can atten-
uate this screening bias 8 and increase detection
of suspected child abuse. 9 Failure to recognize
and report suspected abuse represents a missed
opportunity to protect a child from future injury,
which could have dire consequences as mortality
has been shown to increase with recurrent epi-
sodes of abuse. 10 Overscreening for abuse can re-
sult in increased medical cost, discomfort to the
child during testing, and potentially unwarranted
exposure to radiation.
A pathway containing evidence-based
practice standards for the evaluation of physical
abuse was adopted by the Trauma Council at
Arkansas Children’s Hospital (ACH) in February,
2011. A link to the infant skeletal pathway can be
found at http://www.archildrens.org/programs-
services/a-to-z-services-list/trauma-services/
trauma-education-and-resources. The American
Academy of Pediatrics recommends a complete
skeletal survey in all children younger than two
years when physical abuse is suspected. 3 The
Infant Skeletal Trauma pathway expanded this
screening process to include a skeletal survey in
all infants (<12 months of age) who presented
with any fracture, regardless of suspicion for
abuse, that was not clearly related to a major
trauma event such as a motor vehicle crash.
The pathway also included screening for other
occult injuries when indicated by examination
findings or when there was a suspicion of abuse.
This included obtaining a urinalysis and liver/
pancreatic enzymes for occult abdominal trauma
as well as neuro-imaging. 4
The pathway was approved by members of
the Trauma Council at ACH, which includes rep-
resentatives from Pediatric Trauma Surgery, Pe-
diatric Emergency Medicine, Pediatric Orthope-
dics, General Pediatrics, Pediatric Radiology, Pe-
diatric Neurosurgery, and Child Abuse Pediatrics.
Non-adherence to the pathway was addressed
through ongoing quality assurance case reviews
by the Trauma and Child Abuse teams at ACH.
Methods
A retrospective chart review was performed
for infants who presented to ACH and had a skel-
etal survey ordered as part of the pathway over a
three-year period.
Information included for analysis includ-
ed: index fracture, age, race, co-occurring med-
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