The second skeletal survey found extra fractures in 7% of children investigated for abuse

Design

Retrospective single-centre audit, 2018–2025

Population

168 children under 2 years investigated for suspected non-accidental injury, Wales

Primary outcome

Additional fractures detected on primary and secondary skeletal surveys

Effect

Primary 6.0%; secondary 7.1% additional; 0.6% fracture found only on secondary

UK safeguarding guidance advises two skeletal surveys within two weeks in children under two with suspected non-accidental injury: a full primary survey (with CT head under one year) and a follow-up of selected views of chest and long bones, which catches healing fractures invisible at first. Some have argued that the second survey rarely adds enough to justify the radiation.

This audit at the Children's Hospital for Wales reviewed 168 children under two investigated between 2018 and 2025. Most presented with bruising (106), fractures (43) or domestic violence concerns (15). The primary survey found additional fractures in 6.0%. The secondary survey found additional fractures in 7.1% — and in one child (0.6%) with a normal primary survey, the only fracture appeared on the second.

The numbers are small and from one centre, but the direction is clear: the second survey finds injuries that change the safeguarding picture. Adherence was high (96% within 14 days), showing it can be done.

• In a child under two with suspected physical abuse, arrange both the primary and a follow-up skeletal survey within about two weeks.
• A normal first survey does not exclude occult fractures — rib and metaphyseal fractures often show only as they heal.
• Bruising in a non-mobile infant is itself a trigger for full investigation.
• Add CT head for infants under one year.
• Document the follow-up survey date before discharge so it is not lost.

Why it matters

It answers the argument that the second survey is unnecessary radiation, with data showing it changes what is found.

Don't overread it

A single-centre audit of 168 children — useful confirmation, not a precise estimate of yield.

The statistics, in plain English

Seven per cent of 168 is 12 children; a different centre could plausibly see anywhere from about 4% to 12%. Even at the lower end, the second survey adds information in a meaningful minority.

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