Introduction of Wood's criteria for skeletal survey assessment: the impact of changing local imaging policy

Hannah Jacob

North Middlesex University Hospital

Dr Hannah Jacob is a paediatric registrar working in North London. Her interests include medical education, safeguarding and diabetes. She developed the national undergraduate child health syllabus in the United Kingdom and is heavily involved in the Royal College of Paediatrics and Child Health Trainee Committee. She has three daughters and a very tolerant husband

Rebecca Hewitson

North Middlesex University Hospital

Dr Rebecca Hewitson is a paediatric registrar in North East London. She has enjoyed working in hospitals serving some of London's most deprived populations and the challenges that entails. She has a passion for quality improvement and education and has authored an award-winning textbook "The Hands-on Guide to Practical Paediatrics".

Gayle Hann

North Middlesex University Hospital

Dr Gayle Hann worked as a research psychologist for Cornwall Alcohol and Drugs Agency after graduating from the University of Plymouth. She spent many years working in orphanages in Romania. She retrained as a doctor at the University of Sheffield, graduating in 2002. She is a member of the Royal College of Paediatrics and Child Health. She has been a consultant at the North Middlesex University Hospital since 2013 and is the named doctor for child protection and the lead for paediatric emergency medicine. In addition to her paediatric workload she is a senior lecturer at University College London and a member of the NHS England FGM Steering Group. She is an author and co-editor of the Child Protection Practice Manual: Training Practitioners How to Safeguard Children, published by the Oxford University Press in 2016.

Abstract

ObjectivesWood et al1 proposed criteria to perform a skeletal survey (SS) in children under 2 years presenting with a fracture. The criteria were designed in collaboration with child abuse experts using a modified Delphi... [ view full abstract ]

Objectives

Wood et al¹proposed criteria to perform a skeletal survey (SS) in children under 2 years presenting with a fracture. The criteria were designed in collaboration with child abuse experts using a modified Delphi process and clinical scenarios from published case studies. This study aimed to establish whether introducing Wood’s criteria would impact on the number of SS performed and/or the yield of unreported fractures.

Methods

We conducted a retrospective case notes review over two years; before and after the implementation of Wood’s criteria at a London teaching hospital serving a highly deprived community. The electronic records of all children under 2 years old presenting with a fracture were cross-checked against data for SS. Data on age, mechanism of injury, presentation delay and fracture type sustained were recorded. For each patient, it was documented whether the criteria indicated SS and if fractures were identified with all records reviewed by two researchers.

Results

109 children sustained fractures, 64 before the policy change and 45 after. The mean age of children suffering a fracture was 16 months, the mean age for undergoing SS was 10.5 months and for additional fracture on SS 3.5 months.

5/64 (8%) children underwent SS before the policy change and 13/45 (29%) afterwards, amounting to a greater than two-fold increase. Beforehand, in 1/64 children (2%) occult fractures were identified, whereas after introducing Wood’s criteria this increased to 3/45 children (7%). Additionally all fractures found on SS demonstrated radiological appearances typical of abusive trauma.

Conclusions

Though caution needs to be applied interpreting the small numbers in this study, our results suggest that the incorporation of Wood’s criteria into clinical practice may increase the yield of identifying occult fractures. Such a policy appears workable in a busy district general hospital, but also requires balancing of radiation risks.

Authors

Hannah Jacob (North Middlesex University Hospital)
Rebecca Hewitson (North Middlesex University Hospital)
Gayle Hann (North Middlesex University Hospital)

Topic Area

Physical and Emotional/Psychological Abuse and Neglect

Session

Oral2 » Session 1-Child Physical & Emotional Abuse (11:00 - Monday, 2nd October, S. America)

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