Pediatric Radiology

, Volume 42, Issue 4, pp 463–469 | Cite as

Long bone fracture detection in suspected child abuse: contribution of lateral views

  • Boaz Karmazyn
  • Ryan D. Duhn
  • S. Gregory Jennings
  • Matthew R. Wanner
  • Bilal Tahir
  • Roberta Hibbard
  • Ralph Hicks
Original Article



ACR guidelines for routine skeletal survey for child abuse recommend only AP radiographs of the long bones; however, many institutions add lateral radiographs.


To evaluate whether adding lateral radiographs for long bones changes the frequency and confidence of fracture detection in skeletal survey radiographs for suspected abuse.

Materials and methods

We identified 100 children younger than 2 years of age who underwent skeletal survey for child abuse; 56 with multiple long bone fractures, 22 with a single fracture and 22 with no fractures. Four radiologists (two pediatric radiologists, one pediatric radiology fellow and one general radiologist) evaluated two randomized series (one series included only frontal, and the other series, frontal and lateral radiographs). Likert scale of 1–5 was used to score for detection of metaphyseal and diaphyseal fractures.


For combined readers, significantly more metaphyseal fractures (P = 0.01) were detected with the two-views series of radiographs compared with the frontal-only view; there was no significant difference for diaphyseal fractures. Confidence was also significantly higher for the two-views series. Kappa improved (from 0.32 to 0.48) when the lateral view was added only for the metaphyseal fractures.


Adding lateral radiographs resulted in increased detection and confidence levels of metaphyseal fractures.


Child abuse Fracture ACR guidelines Skeletal survey 


  1. 1.
    Offiah A, van Rijn RR, Perez-Rossello JM et al (2009) Skeletal imaging of child abuse (non-accidental injury). Pediatr Radiol 39:461–470PubMedCrossRefGoogle Scholar
  2. 2.
    Alexander R, Crabbe L, Sato Y et al (1990) Serial abuse in children who are shaken. Am J Dis Child 144:58–60PubMedGoogle Scholar
  3. 3.
    Jenny C, Hymel KP, Ritzen A et al (1999) Analysis of missed cases of abusive head trauma. JAMA 281:621–626PubMedCrossRefGoogle Scholar
  4. 4.
    American College of Radiology (2009) ACR appropriateness criteria. Available via Accessed 11 May 2011
  5. 5.
    Kleinman PK (1998) Diagnostic imaging of child abuse. Mosby, St. Louis, pp 18–25Google Scholar
  6. 6.
    Carty H, Pierce A (2002) Non-accidental injury: a retrospective analysis of a large cohort. Eur Radiol 12:2919–2925PubMedGoogle Scholar
  7. 7.
    King J, Diefendorf D, Apthorp J et al (1988) Analysis of 429 fractures in 189 battered children. J Pediatr Orthop 8:585–589PubMedGoogle Scholar
  8. 8.
    Loder RT, Bookout C (1991) Fracture patterns in battered children. J Orthop Trauma 5:428–433PubMedCrossRefGoogle Scholar
  9. 9.
    Kleinman PK (2008) Problems in the diagnosis of metaphyseal fractures. Pediatr Radiol 38(Suppl 3):S388–S394PubMedCrossRefGoogle Scholar
  10. 10.
    ACR–SPR practice guideline for skeletal surveys in children (2011) Available via Accessed 11 May 2011
  11. 11.
    Section on Radiology; American Academy of Pediatrics (2009) Diagnostic imaging of child abuse. Pediatrics 123:1430–1435CrossRefGoogle Scholar
  12. 12.
    British Society of Paediatric Radiology. Standard for skeletal surveys in suspected non-accidental injury (NAI) in children. Available via Accessed 20 June 2010
  13. 13.
    Kleinman PL, Kleinman PK, Savageau JA (2004) Suspected infant abuse: radiographic skeletal survey practices in pediatric health care facilities. Radiology 233:477–485PubMedCrossRefGoogle Scholar
  14. 14.
    Greenspan A (2000) Orthopedic radiology, 3rd edn. Lippincott Williams & Wilkins, Philadelphia, pp 275–1197Google Scholar
  15. 15.
    Harlan SR, Nixon GW, Campbell KA et al (2009) Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed? Pediatr Radiol 39:962–968PubMedCrossRefGoogle Scholar
  16. 16.
    Don S (2004) Radiosensitivity of children: potential for overexposure in CR and DR and magnitude of doses in ordinary radiographic examinations. Pediatr Radiol 34(Suppl 3):167–172CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Boaz Karmazyn
    • 1
  • Ryan D. Duhn
    • 2
  • S. Gregory Jennings
    • 3
  • Matthew R. Wanner
    • 1
  • Bilal Tahir
    • 3
  • Roberta Hibbard
    • 4
  • Ralph Hicks
    • 4
  1. 1.Department of Radiology and Imaging Sciences, Riley Hospital for ChildrenIndiana University School of MedicineIndianapolisUSA
  2. 2.Kalamazoo DivisionAdvanced Radiology ServicesKalamazooUSA
  3. 3.Department of Radiology and Imaging SciencesIndiana University School of MedicineIndianapolisUSA
  4. 4.Department of Pediatrics, Section of Child Protection ProgramsIndiana University School of MedicineIndianapolisUSA

Personalised recommendations