Development of Guidelines for Skeletal Survey inYoung Children With Fractures

WHAT’S KNOWN ON THIS SUBJECT: Rates of performing skeletalsurvey (SS) for young children presenting with fractures and atrisk for abuse vary substantially across providers, withdisparities associated with patients’ characteristics. Lack ofconsensus regarding indications for SS also contributes to thisvariation.

WHAT THIS STUDY ADDS: The results of this study provide a set ofexplicit consensus guidelines, based on the literature and on theknowledge of experts from several medical specialties, foridentifying children with fractures who should undergo an initialSS.

abstractOBJECTIVE: To develop guidelines for performing initial skeletal survey(SS) in children ,24 months old with fractures, based on availableevidence and collective judgment of experts from diverse pediatricspecialties.

METHODS: Following the Rand/UCLA Method, a multispecialty panel of13 experts applied evidence from a literature review combined withtheir own expertise in rating the appropriateness of performingan SS for 525 clinical scenarios involving fractures in children ,24months old. After discussion on the initial ratings, panelists reratedSS appropriateness for 240 revised scenarios and deemed that SSswere appropriate in 191 scenarios. The panelists then assessed inwhich of those 191 scenarios SSs were not only appropriate, but alsonecessary.

RESULTS: Panelists agreed that SS is “appropriate” for 191 (80%) of240 scenarios rated and “necessary” for 175 (92%) of the appropriatescenarios. Skeletal survey is necessary if a fracture is attributed toabuse, domestic violence, or being hit by a toy. With few exceptions,SS is necessary in children without a history of trauma. In children,12 months old, SS is necessary regardless of the fracture type orreported history, with rare exceptions. In children 12 to 23 monthsold, the necessity of obtaining SS is dependent on fracture type.

CONCLUSIONS: A multispecialty panel reached agreement on multipleclinical scenarios for which initial SS is indicated in young childrenwith fractures, allowing for synthesis of clinical guidelines with thepotential to decrease disparities in care and increase detection ofabuse. Pediatrics 2014;134:45–53

AUTHORS: Joanne N. Wood, MD, MSHP,a,b,c OludolapoFakeye, MA,a Chris Feudtner, MD, MPH, PhD,a,b,c ValerieMondestin, BA,a Russell Localio, MPH, PhD,d andDavid M. Rubin, MD, MSCEa,b,c

aDivision of General Pediatrics and PolicyLab, The Children’sHospital of Philadelphia, Philadelphia, Pennsylvania; bLeonardDavis Institute of Health Economics, and Departments ofcPediatrics, and dBiostatistics and Epidemiology, PerelmanSchool of Medicine at the University of Pennsylvania,Philadelphia, Pennsylvania

KEY WORDSchild abuse, child maltreatment, fracture, skeletal survey, trauma

ABBREVIATIONSAAP—American Academy of PediatricsMVC—motor vehicle crashSES—socioeconomic statusSS—skeletal surveyUCLA—University of California Los Angeles

Drs Wood, Rubin, Feudtner, Fakeye, and Localio contributed tostudy concept and design; Dr Wood, Fakeye, and Mondestincontributed to acquisition of data; and all authors contributed toanalysis and interpretation of data, drafting of the manuscript,critical revisions for important intellectual content, andapproval of the manuscript. Dr Wood had full access to all of thedata in the study and takes responsibility for the integrity of thedata and the accuracy of the data analysis. All authors takepublic responsibility for the content presented in themanuscript.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-3242

doi:10.1542/peds.2013-3242

Accepted for publication Apr 16, 2014

Address correspondence to Joanne N. Wood, MD, The Children’sHospital of Philadelphia, 3535 Market St, Room 1517, Philadelphia,PA 19104. E-mail: woodjo@email.chop.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: Dr Wood’s institution has receivedpayment for expert witness court testimony that Dr Wood hasprovided in cases of suspected child abuse; the other authorshave indicated they have no financial relationships relevant tothis article to disclose.

FUNDING: This study was funded by grant 1K23HD071967-01fromthe Eunice Kennedy Shriver National Institute of Child Health andHuman Development. Funded by the National Institutes of Health(NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conflicts of interest to disclose.

PEDIATRICS Volume 134, Number 1, July 2014 45

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Each year, 8000 to 9000 children ,2years old are hospitalized in the UnitedStates with a fracture.1,2 A diagnosis ofphysical abuse is made in approxi-mately 20% to 25% of fracture cases inchildren,12 months old and in 6% to7% for children 12 to 23 months old,1–3

but the true proportion of cases at-tributable to abuse is higher, asmedicalproviders frequently fail to recognizethe abusive origin of injuries in chil-dren.4–6 Fractures are one of the mostcommon injuries for which victims ofabuse seek medical care, but fracturesare also a common accidental injury.7–9

Distinguishing cases of abusive frac-tures from accidental fractures can bedifficult.9,10 Nevertheless, failure of pro-viders to diagnose abuse can resultin children suffering morbidity andmortality from additional undiagnosedinjuries as well as on-going abuse.5,6,11–13

Thus, a thorough evaluation must beperformed in young children with frac-tures that could be suspicious forabuse.9,10,14

Young victims of abuse frequently haveoccult fractures or fractures that arenot suspected on history and physicalexamination but revealed on skeletalsurvey (SS), a series of ∼20 radio-graphs.14–21 In addition to using SS toidentify occult fractures in childrenpresenting with injuries that areclearly the result of abuse, cliniciansuse SS in determining level of concernfor abuse in young children presentingwith injuries of unclear etiology.15,20

Hence, recommendations of the Amer-ican Academy of Pediatrics (AAP) em-phasize performing SS in cases ofsuspected physical abuse in children,2 years old.14,15 SSs, however, exposechildren to radiation, and the AAPadvises against SS in cases in whichoccult injuries are unlikely.

Hospital-based variation in using SSfor evaluation of possible abuse hasbeen documented.22 Quality concernsare raised in studies highlightingmissed

opportunities to diagnose abuse.5,6,9,11–13,23

Research also has revealed disparitiesin the frequency of performing SS anddiagnosing abuse in children withfractures based on race and socio-economic status (SES) of families.24–27

The observed disparities raise con-cern for underevaluation and under-diagnosis of abuse in some groups(white, high SES), as well as over-evaluation and overdiagnosis of abusein other groups (racial minority, lowSES).

Efforts to reduce disparities and im-prove quality of care provided to chil-dren with injuries suspicious of abusehave been hindered by the lack of clearcriteria regarding when SS is neces-sary. The AAP recommends SS in casesof suspected abuse, but the term“suspected” is not defined and maybe interpreted differently by clini-cians.15,20 In a recently updated report,the AAP provided additional valuableguidance to clinicians on the manyfactors to consider when identifyingchild abuse as the cause of fractures.9

Concrete recommendations on whichspecific fracture scenarios shouldraise suspicion for abuse and promptordering of SS, however, are notavailable. The goal of this study was todevelop guidelines for initial SS inyoung children presenting with frac-tures, with emphasis on includinga diversity of provider perspectives.The explicit target for the guidelineswas children ,2 years old, becauseSS is less likely to reveal occult frac-tures in older children.15

METHODS

We applied the Rand/UCLA Appropri-ateness Method, which combines ex-pert opinion and evidence, to identifyclinical scenarios for which SS is ap-propriate, as well as scenarios forwhich SS is not only appropriate, butalso necessary.28 The Rand method,a modified Delphi process that pro-

vides expert panelists with the oppor-tunity to discuss their judgments, hasbeen shown to have high content,construct, and predictive validities fordeveloping appropriateness criteria.29–31

Per Rand definitions, a procedure isappropriate for a scenario if the ex-pected health benefit exceeds theexpected negative consequences “by asufficiently wide margin to make itworth doing, exclusive of cost.”28 Aprocedure is necessary if it has beendeemed appropriate and meets thefollowing additional criteria: (1) notoffering the procedure would be im-proper, (2) there is a reasonable chanceof the procedure benefiting the patient,and (3) the magnitude of the benefit isnot small.28

Following Rand protocol, 3 preparatorysteps were completed: (1) compilinga literature review on SS in childrenwith fractures, (2) generating a list ofclinical scenarios/vignettes that char-acterized children with fractures forwhom SS might be considered, and (3)convening a panel of experts (Fig 1).Then, the following processes werecompleted sequentially: (1) panelistsrated the appropriateness of SS foreach clinical scenario (Round 1); (2)panelists reviewed the ratings andmade revisions to scenarios duringa moderated discussion; (3) panelistsrerated the appropriateness of SSfor the revised list of scenarios(Round 2); (4) scenarios were cate-gorized as appropriate, uncertain,or inappropriate for SS based onRound 2 ratings; (5) panelists ratedthe necessity of SS for scenariospreviously categorized as appropri-ate (Round 3); and (6) appropriatescenarios were further categorizedas necessary or unnecessary for SSbased on Round 3 ratings.

The Children’s Hospital of Philadelphia’sInstitutional Review Board exemptedthis study as non–human subjectsresearch.

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Literature Review

Based on the literature review inPubMed/Medline of English languagejournals published between 1990 and2011, and excluding surveys, reviews,editorials, andcasestudies, theauthorssynthesized the evidence on (1) efficacy,risks, utilization trends, and costs of SSin children with fractures; (2) proba-bility of abuse in children with frac-tures; and (3) probability of occultfractures in children presenting withfractures. Titles and abstracts of iden-tified studies were screened and non-relevant studies were eliminated. Fullmanuscripts for the remaining studieswere reviewed for eligibility. Using astandardized form, 3 of the authors(J.W., O.F., V.M.) extracted the followingfrom 41 included studies: (1) studypopulation characteristics, (2) inclusionand exclusion criteria, (3) methodologyused to diagnose abuse, and (4) pro-portion of study population and sub-populations diagnosed as abused. Theprobability of abuse with 95% confi-dence intervals was calculated forchildren with specific fracture types.Finally, we calculated sensitivity, speci-ficity, and positive and negative like-lihood ratios of different clinicalcharacteristics for abuse. See Sup-plemental Appendix 1 for the list ofincluded studies.

Expert Panel Assembly

A panel of 13 experts representing adiverse set of clinical views28,32,33 was

recruited from key pediatric special-ties, including child abuse, emergencymedicine, trauma, radiology, and or-thopedics (Supplemental Appendix 2).Panelists were identified through thefollowingmechanisms: (1) nominations,including self-nominations, from indi-viduals with leadership roles in nationalprofessional organizations; (2) reviewof the literature to identify individualspublishing in the field; and (3) andsolicitations of recommendations fromcolleagues. Panelists were purposivelyselected to ensure diversity with re-spect to practice location (Northeast,Midwest, West, and South), demographiccharacteristics, and practice experience(1–23 years).

Appropriateness Criteria:Development of Scenarios andRound 1

A Web-based questionnaire developedin Research Electronic Data Capture34

listed 525 clinical scenarios organizedinto 8 modules. Each scenario char-acterized a child with a fracture forwhom SS might be considered. Module1 explored the role of the followingparameters on the decision to obtainSS in a child with a fracture: (1) delay inseeking care, (2) additional injuries onphysical examination, and (3) reportedhistory of injury resulting from do-mestic violence or abuse. The remain-ing 7 modules were organized byfracture group (femur, humerus, rib,tibia/fibula, radius/ulna, skull, andclavicle). The parameters for each sce-

nario in these 7 fracture modules wereas follows: child age, reported history oftrauma, fracture type. Scenarios werepilot-tested for clarity and modified asneeded.

Via e-mail, each panelist received anintroduction to the study, an electroniclink to the questionnaire, literaturereview results, and standard instruc-tions on rating the appropriateness ofperforming initial SS on a Likert scaleof 1 to 9 for each scenario, with 1 =Extremely Inappropriate, 5 = Uncertain,and 9 = Extremely Appropriate. Panel-ists were advised to use the evidencefromthe literaturereviewand theirownclinical judgment to rate the appro-priateness of performing SS consider-ing the average patient who presentsfor care with conditions specified inthe scenario. We asked panelists tomake the following assumptions un-less otherwise specified: (1) patient isnot a victim of a motor vehicle crash(MVC) or other independently wit-nessed accidental trauma, (2) there isno known history of underlying bonedisease (eg, osteogenesis imperfecta,osteopenia of prematurity) in thechild, (3) physical examination doesnot reveal any additional injuriessuggestive of abuse (eg, whip marks,extensive bruising, frenulum tears),and (4) there is not a clear history ofbirth trauma explaining the fracture.In the first round, panelists rated theappropriateness of SS for each sce-nario without interaction with otherpanelists.

FIGURE 1Procedure of the Rand/UCLA Appropriateness Method.

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Appropriateness Criteria Rating:Moderated Conference Call,Rounds 2 and 3

In preparation for Round 2, each pan-elist received an anonymized summaryof the panel’s ratings and their ownindividual ratings for each scenariofrom round 1. During a moderated tele-phone conference, panelists discussedthe ratings, focusing on scenarios inwhich there was disagreement. If thewording of a scenario was ambiguous,panelists proposed and voted on mod-ifications to clarify the description.Based on consensus reached duringthe conference, some fracture subtypeswere altered. Some scenarios with sim-ilar ratings were also collapsed intoa single scenario, reducing the origi-nal 525 scenarios to 240. For example,the rib module initially included 100scenarios, but panelists rated SS ap-propriate for all scenarios and agreedto collapse the entire rib module intoa single scenario. After the confer-ence, panelists independently ratedthe appropriateness of SS for each ofthe 240 revised scenarios. The medianrating and dispersion of ratings foreach scenario was calculated. PerRand methodology, we classified sce-narios for which ratings of #3 pan-elists were outside each 3-pointregion containing the median as hav-ing agreement, and scenarios forwhich 4 or more panelists’ ratingswere in each extreme (1–3 and 7–9)as having disagreement.27 Scenarioswith median ratings of 7–9 withoutdisagreement were categorized as“appropriate” and those with medianratings of 1–3 without disagreementas “inappropriate.” Scenarios withmedian ratings of 4–6 or any medianwith disagreement were categorizedas “uncertain.”

In round 3, panelists independentlyrated the necessity of SS for scenariosthat were classified as appropriate inround 2. Scenarioswithmedian ratings

of 7 to 9 without disagreement werecategorized as “necessary” and thosewith median ratings of 1 to 3 withoutdisagreement as “appropriate but notnecessary.” Median ratings of 4 to 6 orany median with disagreement werecategorized as “appropriate but uncertainwhether necessary.”

Summary guidelines were synthe-sized from the categorizations ofscenarios in rounds 2 and 3 by thestudy team.

RESULTS

Agreement was reached that SS wasappropriate in 79.6% (191), uncertainin 19.6% (47), and inappropriate in0.8% (2) of the 240 scenarios rated inround 2. In 40 of the 47 scenarioscategorized as uncertain, panelistsagreed that there was uncertaintyabout the appropriateness of SS,whereas there was disagreement in7 scenarios. The greatest disagree-ment was observed in scenarios in-volving children 12 to 23 months oldwith nonmetaphyseal fractures froma reported fall. Of the 191 scenariosfor which SS was deemed appropri-ate, 175 (91.6%) were confirmed asnecessary.

General Fractures Scenarios

Panelists determined that SS is nec-essary for children 0 to 23 months old

with fractures from abuse or domesticviolence and for children with addi-tional injuries unrelated to the fracture(ie, bruises, burns, whip marks). Pan-elists agreed that a delay in seekingcare of.24 hours is an indication forSS in children 0 to 11 months old re-gardless of the fracture type orsymptomatology (Table 1). In children12 to 23 months old with a delay incare of .24 hours, SS is necessaryonly if the fracture is associated withsignificant pain and/or physical find-ings.

Long-Bone Fractures

Panelists determined that SS is nec-essary in children 0 to 11 months oldwith long-bone fractures regardlessof history, with 2 exceptions: a distalradius/ulna buckle fracture or tod-dler fracture in children 9 to 11months old with a reported fall whilecruising or walking (Table 2). Inchildren 12 to 23 months old, theappropriateness and necessity of SSvaried with fracture type and history.SS was deemed necessary in allcases of a classic metaphyseal lesionand for fractures attributed to beinghit by a toy or other object. Skeletalsurvey was judged inappropriate inchildren 12 to 23 months old witha long-bone fracture in 2 scenarios:(1) distal radius/ulna buckle fracture

TABLE 1 Appropriateness and Necessity of SS for Children ,24 Months Old With a Delay inPresentation to Care

Time FromInjury, h

Age, mo Fracture Types Symptomatology

No Obvious Injury or Distress Obvious Injury With Distress

0–11 Long bone N N24–72 Skull N N

12–23 Long bone U NSkull U N

0–11 Long bone N N$72 Skull N N

12–23 Long bone A NSkull U N

Summary of panelists’ ratings on clinical scenarios related to delay in presentation of care, across fracture groups andstratified by age. A, SS appropriate but not necessary; N, SS appropriate and necessary; U, uncertain whether SS isappropriate or not.

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with history of a fall onto an out-stretched hand, and (2) tibia/fibulatoddler fracture with history of a fallwhile walking. These were the onlyscenarios for which SS was deemedinappropriate.

Skull Fractures

Panelists agreed that SS is appropriatefor all skull fracture cases in children0 to 11 months old (Table 3). The pro-cedure was deemed necessary forskull fractures in this age group, withthe exception of infants 7 to 11 monthsold with linear, unilateral skull frac-tures attributed to a reported fall from

a high height or from a fall with thecaregiver landing on the child. Skeletalsurvey was regarded necessary in allcases of complex or ping-pong skullfractures.

Rib Fractures

Panelists agreed that SS is necessaryfor children 0 to 23 months old withrib fractures regardless of child age,history of trauma, and fracture loca-tion or number.

Clavicle Fractures

Given the possibility of birth injury,SS was of uncertain appropriateness

for infants#10 days old with an acuteclavicle fracture and no history oftrauma (Table 4). SS was appropriatebut not necessary for infants 11 to 21days old with acute fractures and in-fants ,30 days old with healing frac-tures. Outside of the neonatal period,SS was pronounced necessary in allchildren ,24 months old with excep-tion of children 12 to 23 months oldwith a history of a fall.

DISCUSSION

Drawing on a review of the literatureand using the Rand/UCLA Appropriate-ness Method, a multispecialty expert

TABLE 2 Appropriateness and Necessity of SS for Children With Long-Bone Fracture

Fracture Group Age, mo Fracture Types Caregiver-Reported History of Trauma

None BluntImpacta

Fall While Cruising,Walking, Runningb

Short Fall(#3 ft)

High Fall(.3 ft)

Fall FromCaregiver Arms

Fall With CaregiverLanding on Child

0–11 Any N N N N N N NCML N N N N N N NSalter with epiphyseal

separationcN N A N A A A

Humerus 12–23 Salter without epiphysealseparation

N N U U U U U

Supracondylar N N U U U U UDiaphyseal N N U U U U U

0–11 CML N N N N N N NFemur Diaphyseal N N N N N N N

12–23 CML N N N N N N NDiaphyseal N U U N N U U

0–11 CML N N N N N — —

Proximal buckle N N N N N — —

Radius/ulna Distal buckle N N U N N — —

All others N N N N N — —

12–23 CML N N N N N — —

Proximal buckle N N U U U — —

Distal buckle A N I U U — —

All others N N U U U — —

0–11 CML N N N N N — —

Toddler (distal spiral) N N U N N — —

Tibia/fibula Buckle N N N N N — —

All others N N N N N — —

12–23 CML N N N N N — —

Toddler (distal spiral) U N I U U — —

Buckle A N U U U — —

All others N N N A U — —

Summary of panelists’ ratings on clinical scenarios related to presentations of long-bone fracture types, stratified by age. A, SS appropriate but not necessary; CML, classic metaphyseal lesion;I, SS inappropriate; N, SS appropriate and necessary; U, uncertain whether SS is appropriate or not.—, indicates that a scenario for that particular combination of history and fracture typewas not included in the list of scenarios rated by the panelists.a Blunt impact was defined as being hit by a toy or other object, except for femur fracture it was defined as another person landing on child’s leg.b This scenario was limited to children $9 mo who are able to cruise or ambulate. For radius/ulna fractures, the scenario specifies that child fell onto an outstretched hand.c Includes Salter Type 1 fractures.

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panel agreed on 175 clinical scenariosfor which initial SS is appropriate andnecessary in children,24 months oldwith specific fractures, permitting syn-thesis of guidelines for performing SS inthis age group (Fig 2). First, panelistsagreed that SS should be performed inchildren whenever a fracture is attrib-uted to abuse, domestic violence, or tobeing hit by a toy or similar object.Second, they agreed that SS should beobtained in children with rib fracturesand in children without a history oftrauma to explain their fracture, ex-cept in the ambulatory child $12months old with a toddler fracture orbuckle fracture of the radius/ulna ortibia/fibula. Third, panelists univer-sally endorsed SS for children ,12

months old with fractures, with a fewnoted exceptions. For children $12months old, however, there was moredisagreement on appropriatenessof SS. Appropriateness of the pro-cedure for this age group dependsmore on fracture type than for the,12-month age group. The panelrarely found SS inappropriate forthis population, possibly to allowleeway for consideration of otherfactors that may increase suspicionfor abuse, such as a history of pre-vious abuse.

Given the significant risk of abuseamong children,12 months old withfractures, it is not surprising thatthese guidelines, like the AAP rec-ommendations, advocate for almost

universal SS screening in this pop-ulation.1,2 Current clinical practices,however, diverge from these guide-lines. In a recent study, only three-quarters of infants ,12 months oldadmitted to pediatric hospitals withnon–MVC-related femur fracturesreceived SS.22 In another study, fewerthan half of infants ,12 months oldwith complex skull fractures receivedSS.25 Thus, these guidelines have thepotential to alter current clinicalpractice.

The use of Rand methodology in thisstudy is not without limitations. Resultsfrom this process could vary based onthe selected panelists’ specialties.28

Although we included experts fromvarious specialties purposely to pro-vide diverse views, the opinions ofour experts might not reflect the arrayof views of colleagues in their fields.Additional factors that were not cap-tured in scenarios rated, such ascomprehensive history of trauma, pre-vious history of abuse, and observedcaregiver-child interactions, might in-fluence actual appropriateness andnecessity determinations of SS. Finally,although the expert panel benefitedfrom a review of the literature to in-form their ratings, the available evi-dence is limited, and the panelistswere allowed to incorporate their ownopinions in decision-making. Thus, thereis some uncertainty about the effec-tiveness of these guidelines to accu-rately identify those children at thehighest risk of having occult fracturesfrom abuse.

Despite these limitations, the resultsfrom this study provide a set of explicitconsensus guidelines for performinginitial SS in children with fractures.Research has demonstrated thatthe implementation of SS guidelinesfor injured children could decreasedisparities in care and potentiallyincrease abuse detection.35 Missedopportunities to diagnose abuse lead

TABLE 3 Appropriateness and Necessity of SS for Children With Skull Fracture

FractureGroup

Age, mo Fracture Type Caregiver-Reported History of Trauma

None Short Fall(#3 ft)

High Fall(.3 ft)

Fall FromCaregiver Arms

Fall With CaregiverLanding on Child

0–6 Linear/unilateral N N N N NLinear/bilateral N N N N NComplex N N N N NPing-pong N N N N N

Skull 7–11 Linear/unilateral N N A N ALinear/bilateral N N N N NComplex N N N N NPing-pong N N N N N

12–23 Linear/unilateral N A U U ULinear/bilateral N A U U UComplex N N N N NPing-pong N N N N N

Summary of panelists’ ratings on clinical scenarios related to presentations of skull fracture types, stratified by age. A, SSappropriate but not necessary; N, SS appropriate and necessary; U, uncertain whether SS is appropriate or not.

TABLE 4 Appropriateness and Necessity of SSs for Children With Clavicle Fracture

Fracture Group Child Age Reported History and Age of Fracture

No History of Trauma Fall Blunt Impacta

Acute Fracture Healing Fractureb Acute Fracture Acute Fracture

0–10 d U A N N11–21 d A A N N

Clavicle 22–30 d N A N N1–11 mo N N N N

12–23 mo N N U N

Summary of panelists’ ratings on clinical scenarios related to presentations of clavicle fracture types, stratified by age indays. A, SS appropriate but not necessary; N, SS appropriate and necessary; U, uncertain whether SS is appropriate or not.a Blunt impact was defined as being hit by a toy or other object.b Scenarios described children with healing fractures discovered incidentally during chest imaging performed for unrelatedmedical reasons.

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not only to additional injuries directlyrelated to the abuse, but also couldcontribute to chronic medical conditionsand overall mortality.36–39 Thus, guide-lines that improve early detection anddiagnosis of abuse may affect not onlyabuse-related injuries, but also a widerange of adverse health outcomes. Theguidelines developed in this study arenot part of and are not intended to con-flict with the recommendation of the AAPSection on Child Abuse to perform SS incases of suspected physical abuse inchildren,24 months old.14 Instead, theyare purposed to provide additionalguidance to clinicians on specific sce-narios for which it is appropriate tosuspect abuse and perform SS. The

guidelines developed in this study alsocould be applied retrospectively as per-formance measurement tools: the ap-propriateness criteria could be used tomeasure SS overuse, whereas the ne-cessity criteria could be used to assessSS underuse. As the development ofthese guidelines relied on expert opinionand the limited evidence available, futurestudies evaluating the predictive validityof the guidelines to identify children withpositive screens for occult fractures arewarranted.

CONCLUSIONS

Applying the Rand/UCLA Appropri-ateness Method, a multispecialtypanel reached agreement on clinical

scenarios for which initial SS is neces-sary in young children with fractures,permitting synthesis of guidelines forperforming initial SS in this population.Postimplementation evaluation of theseguidelines is needed to determinewhether they achieve the goals of (1)decreasing variation and disparities incare, (2) increasing detection of casesof abuse, and (3) decreasing use of SSin children with low risk for occultfractures.

ACKNOWLEDGMENTSWe thank the panelists for the time, ef-fort andexpertise they dedicated to thisproject. See Supplemental Appendix 2for a profile of the panelists.

FIGURE 2Summary of Key Skeletal Survey Guidelines. The guidelines synthesize the panelists’ responses fromTables 1, 2, 3, and 4. They apply to childrenwho do not havea verifiable mechanism of accidental trauma (ie, MVC or fall in public place), do not have underlying bone fragility, such as osteogenesis imperfecta, and whodo not have a clear history of birth trauma that accounts for the injury.

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PROTEIN AND LIFE EXPECTANCY: For years, many weight loss advocates havesuggested that a high protein diet is the best way to lose weight. Indeed, severalstudies have shown that high-protein, low-carbohydrate diets are effective forweight loss and can help normalize blood-glucose levels. The long term outcomeof high protein diets, however, has not been known. As reported in The Wall StreetJournal (Life & Culture: March 12, 2014), two recent studies, one in mice and theother in humans, suggest that high protein diets may decrease life expectancy.In theanimal study,more than850micewere fedoneof several different diets eachwitha specific ratio of protein to carbohydrates.Mice that consumedhigher ratiosof protein to carbohydrates were leaner than those who consumed diets witha lower protein to carbohydrate ratio. However, the high protein diets came ata price: decreased life expectancy. Mice with diets consisting of lower amounts ofprotein had a 30% increased life span than those mice who consumed higheramountsofprotein. In thehumanstudy,more than6300adultswere followed for18years after completing a 24 hour food diary. Subjectswere placed into one of threeprotein consumption groups based on the percentage of calories from protein:high (.20%); moderate (10-19%); and low (,10%). Compared to those with lowprotein diets, adults aged 50-65 with moderate and high protein diets had up toa 74% increase in their relative risk of all-cause mortality. Oddly, those over 65seemed to benefit from the high protein diet.How to interpret these data is a bit problematic. For one, humans are not mice.Moreover, inhumans, dietaryhabits canchangeover time. The timingofmealsandthe age of diner may influence results. For example, many Americans eat themajority of protein in theeveningatdinnerandnotall theprotein consumedwill beabsorbed. The elderly may benefit from a high protein diet because protein ab-sorption decreases with age. Given the confusing data, the old adage seemsappropriate: everything in moderation.

Noted by WVR, MD

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Localio and David M. RubinJoanne N. Wood, Oludolapo Fakeye, Chris Feudtner, Valerie Mondestin, Russell

FracturesDevelopment of Guidelines for Skeletal Survey in Young Children With

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FracturesDevelopment of Guidelines for Skeletal Survey in Young Children With

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