title: Occult abusive injuries in infants with apparently isolated skull fractures.
abstract: BACKGROUND
  There is currently no consensus about which screening studies should be undertaken to identify abusive injuries in infants with apparently isolated skull fractures. Our objective was to determine rates of screening, rates of injury identification, and rates of reporting to child protective services among infants who underwent subspecialty evaluation for abuse after presenting with an apparently isolated skull fracture.
  
  
  METHODS
  This was a retrospectively planned, secondary analysis of index children enrolled in a large network of children with concerns for physical abuse. For this analysis, we included infants (<12 months) who presented with signs and symptoms attributable to a skull fracture. We determined rates of skeletal survey, dedicated ophthalmologic examination and abdominal injury screening, rates of injury identification by testing and reports to child protective services.
  
  
  RESULTS
  A total of 215 infants underwent abuse consultation for apparently isolated skull fractures. Skeletal surveys were performed in 201 subjects (93.4%) and identified additional fractures in 12 (5.6%; 95% confidence interval, 2.9-9.6%). Patient age, trauma history, and fracture type (simple/complex) were not sensitive predictors of finding additional fractures on skeletal survey. Only one additional fracture was associated with clinical signs or symptoms. Dedicated ophthalmologic examination was undertaken in 100 subjects (46.5%); one child had retinal hemorrhages. Hepatic transaminases were obtained in 135 subjects (62.7%), and 5 subjects (2.3%) had abdominal computed tomography. No abdominal injuries were identified. A total of 146 subjects (67.9%) were reported to child protective services.
  
  
  CONCLUSIONS
  Infants with apparently isolated skull fractures are an important fraction of consultations for physical abuse. Additional fractures are identified in a small subset of the skeletal surveys completed in these children.
  
  
  METHODS
  Epidemiological study, level IV.
authors.affiliation: Freddie Mac Foundation Child and Adolescent Protection Center (K.P.D.),Children's National Medical Center, George Washington University School ofMedicine and Health Sciences, Washington, District of Columbia, USA.
authors.forename: Katherine P
authors.initials: KP
authors.lastname: Deye
authors.forename: Rachel P
authors.initials: RP
authors.lastname: Berger
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Lindberg
mesh_terms: D002649:Child Abuse / Q000175:diagnosis*; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009104:Multiple Trauma / Q000175:diagnosis / Q000209:etiology; D012189:Retrospective Studies; D012887:Skull Fractures / Q000175:diagnosis* / Q000209:etiology