By David Ferguson
Nearly half of children with abuse-related injuries are not properly screened for hidden fractures, in spite of that procedure's accuracy in determining cases of abuse, according to a study published in the journal Pediatrics. The study also found that race and socioeconomic status play a role in these discrepancies.
The skeletal survey is a series of X-rays taken of a child's full skeleton to determine the presence of broken bones that may not be apparent to the naked eye. These breaks are called occult fractures. The American Academy of Pediatrics mandated the test for all children under two years of age who present signs of possible abuse-related injuries.
"In the young population, medical providers can miss important injuries," senior study author Joanne Wood, M.D., an assistant professor of pediatrics at the University of Pennsylvania Perelman School of Medicine, told Kaiser Health News. "Skeletal surveys can help identify them."
The study examined data from 4,486 patients younger than 2 who providers diagnosed as victims of abuse or injuries often associated with abuse. The study included 366 hospitals and ran from 2009 to 2013. Forty-eight percent of children with an abuse diagnosis and 51 percent of infants with traumatic brain injury were evaluated with a skeletal survey for occult fracture. Of infants with femur fractures, only 53 percent of the cases across the nation were examined for further fractures.
Pediatric hospitals fared significantly better, however. In a previous study by Wood and her colleagues, 83 percent of similar cases underwent skeletal surveys at hospitals that specialize in pediatric medicine.
Furthermore, there is a sharp socioeconomic and racial divide between which patients receive the screening and which do not, echoing broader trends within healthcare. Black children were half as likely as white children to undergo a skeletal survey as part of an abuse diagnosis, whereas Hispanic were nearly twice as likely to receive the screening as white children. Infants with traumatic brain injuries were more likely to be evaluated if they receive government health insurance.
"Over the past 25 years, research has repeatedly highlighted missed opportunities to evaluate and diagnose abuse in young, injured children suffering from undiagnosed injuries as well as ongoing abuse," researchers wrote. "Research has also revealed that racial and [socioeconomic status–based] biases influence decision-making regarding child abuse evaluations and diagnoses."
Standardized, universal fracture evaluation for all children who present with these types of injuries could eliminate these inequities of treatment and detection.
"The marked variation in occult fracture evaluation rates among infants with high-risk injuries raises concerns for missed opportunities to detect abuse and protect children," the study concluded. "These results highlight an opportunity to improve quality of care for this vulnerable population."
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