A second skeletal survey still finds fractures in children under 2 assessed for abuse

Design

Retrospective single-centre audit

Population

168 children under 2 years with primary and secondary skeletal surveys for safeguarding, Wales

Primary outcome

Fractures found on primary and secondary surveys

Effect

Additional fractures 6.0% on primary survey and 7.1% on secondary; 0.6% had a fracture found only on the secondary survey

This retrospective audit reviewed every skeletal survey done for safeguarding in children under 2 at the Children's Hospital for Wales between 2018 and early 2025. UK guidance recommends a full survey followed by a limited second survey within two weeks, and recent work had questioned whether the second radiation dose was justified.

Of 168 children with both surveys, 6.0% had fractures beyond the presenting injury on the first survey. On the second survey, 7.1% had additional fractures, and one child (0.6%) had a normal first survey with a fracture found only on the second. Most children had presented with bruising or skin lesions.

Healing fractures often become visible only as callus forms, which is why the repeat views find injuries the first missed. Where safeguarding decisions depend on the full picture, a second survey adds information that can change the outcome for the child. In Indian practice, formal skeletal survey protocols are applied unevenly, and this is a reminder that one normal survey does not close the question.

• Complete a full skeletal survey in children under 2 with suspected physical abuse
• Book a follow-up survey at about two weeks rather than stopping after one normal study
• Include CT head for infants under 1 year, per UK guidance
• Consider bruising alone in a non-mobile infant a reason for full assessment

Why it matters

It answers the recent argument that the second skeletal survey is not worth its radiation dose.

Don't overread it

This was a single-centre audit of 168 children; rates may differ elsewhere.

The statistics, in plain English

7.1% is 12 of 168 children. The one fracture found only on the second survey is a single case, so its true frequency is uncertain, but in safeguarding a single missed injury can matter.

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