Prevalence of abusive fractures of the hands, feet, spine, or pelvis on skeletal survey: Perhaps "uncommon" is more common than suggested

OBJECTIVE: Recently, it has been suggested that views of the hands, feet, spine, and pelvis should be omitted from routine skeletal surveys (SSs) because these fractures are rarely identified by SS. Our objective was to describe the prevalence of fractures to the hands, feet, spine, or pelvis among SSs obtained for children in a large, multicenter population who underwent consultation for physical abuse. METHODS: This was a retrospective secondary analysis of data from the Examining Siblings To Recognize Abuse research network, a consortium of 20 US child abuse teams who collected data for all children younger than 10 years who underwent consultation for concerns of physical abuse. This secondary analysis included data only from index children and excluded data from siblings and contacts. Consulting child abuse physicians reported the number of fractures identified and those that were detected by SS. RESULTS: Among 2049 initial SSs, 471 (23.0%) showed at least 1 previously unknown fracture including 49 (10.4%) that showed a fracture to the hands, feet, spine, or pelvis. In 10 cases, the SS identified at least 1 fracture of the hands, feet, spine, or pelvis when no other fractures were identified. CONCLUSIONS: A significant number of occult, abusive fractures would have been missed if SSs had omitted or deferred views of the hands, feet, spine, and pelvis. Given the risks associated with missed abuse, these views should be routinely included in the radiographic SS.