Outcomes of indeterminate fractures identified on skeletal surveys obtained during non-accidental trauma evaluations.

BACKGROUND

Skeletal surveys (SS), a critical component of non-accidental trauma (NAT) evaluations, may have indeterminate findings concerning for a possible fracture. The frequency and clinical impact of these indeterminate fractures is unknown.

OBJECTIVES

In children with SS obtained as part of NAT evaluations, 1) determine the prevalence and clinical characteristics of indeterminate fractures, 2) describe frequency and type of follow-up imaging, and 3) ascertain the potential impact of indeterminate fractures.

PARTICIPANTS AND

SETTING

A single-center, retrospective chart review of children <2 years who underwent an initial SS to evaluate for NAT, between January 2020 and March 2024.

METHODS

Descriptive statistics were used to calculate the frequency of indeterminate fractures, clinical characteristics, follow up imaging, and impact.

RESULTS

Of 1198 initial SSs, 153 (13%) had at least 1 indeterminate fracture. These 153 SSs identified a total of 254 indeterminate fractures (median = 1, IQR 1-2), frequently classic metaphyseal lesions (25%, 64/254) or rib fractures (25%, 64/254). Most patients (93%, 143/153) underwent at least one clarifying imaging study; more than half (80, 52%) required >24 h for uncertainty resolution. A minority of indeterminate fractures were ultimately confirmed as true fractures (24%, 60/254). Seventy percent (107/153) of patients had concurrent, definitive injury and 55% (84/153) were referred to child protective services.

CONCLUSIONS

One in eight SSs identified at least one indeterminate fracture, often a fracture type highly specific for NAT. However, most were not true fractures, suggesting opportunities for improvement in SS workflow given the diagnostic implications.