Suspected physical abuse in a child — skeletal survey

RCR/SCoR suspected physical abuse guidance; ESPR/ESR Essentials 2024

A prescribed radiographic series performed as part of a multi-agency child protection process, not an ad-hoc set of films. The imaging is standardised, reported to a defined standard, and followed by a repeat survey after around two weeks because healing changes reveal injuries invisible at presentation.

A child, usually under two years, with an injury that is unexplained, inconsistent with the history or with the developmental stage, or another child in a household where abuse is suspected.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

GCS

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

Skeletal survey — standard prescribed series

Skeletal survey

What we'd amend, and why

The full radiographic skeletal survey is the core investigation because the injuries with the highest specificity for inflicted trauma — classic metaphyseal lesions and posteromedial rib fractures — are small, subtle and frequently clinically silent. Only dedicated, individually collimated, correctly exposed views of each region resolve them, which is why the series is prescribed rather than tailored to where the child is sore.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwaychild — Children
rulerule-paeds-dose — Child-sized technique and contrast dose; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(1)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

Child-sized technique and contrast dose
Confirm that a size- or weight-based protocol is selected — child-sized kV and mAs against size-based diagnostic reference ranges — and that contrast volume is calculated by weight rather than taken from an adult default. Weight-based iodinated contrast volumes of roughly 1.5–2.0 mL/kg are widely used in paediatric CT.
Radiographer at the scannerAt the scanner
Flags back if: No paediatric or size-based protocol exists on the scanner for the requested examination, or the requested coverage or number of phases exceeds what the clinical question needs — for example a multiphase study where a single phase answers it, or whole-body coverage for a focal question.
Dose optimisation here means correct exposure and tight collimation on each prescribed view — not fewer views. A survey with missing or non-diagnostic projections must be repeated, which delivers more dose than performing it properly the first time, and in the meantime an injury that carries safeguarding consequences may go undetected.

Worth asking the referrer (2)

None of these hold the request up. They sharpen the protocol or the plan that follows.

How old is the child, and is this request part of an agreed child protection process with a named paediatrician?
Age determines the yield and the composition of the survey, and the safeguarding process determines consent, timing and who receives the report.
Are there neurological signs, a reduced conscious level, or is the child under one year old?
It decides whether head imaging is performed alongside the survey rather than considered later.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Reduced conscious level — head imaging alongside the survey

Role	Study & protocol	Why this answers the question
First line	CT Head CT Head — Unenhanced	A child with suspected inflicted injury and a depressed conscious level needs the head scan now. Unenhanced CT detects acute extra-axial haemorrhage and skull fractures in minutes and without sedation, and it is the study that changes immediate management — decompression, neuroprotection, escalation of care — where the skeletal survey changes the safeguarding picture over the following days. The dose is justified by the severity of what it excludes, and any drop in conscious level in this setting is treated as the neurological sign it is rather than as distress or sleepiness.
First line	Skeletal survey Skeletal survey — standard prescribed series	The prescribed survey is performed alongside the head scan, not instead of it and not after the child has been discharged from the acute phase: the injuries with the highest specificity for inflicted trauma — classic metaphyseal lesions and posteromedial rib fractures — are small, subtle and clinically silent, and only dedicated, individually collimated views resolve them. Timing is the only thing this arm changes about it; the series itself is unchanged, and it is still followed by a repeat survey at around 11 to 14 days.
Problem solving	MRI Brain MRI Brain — routine unenhanced	MRI of the brain, and where indicated the spine, follows CT: it dates collections more reliably, shows parenchymal and hypoxic-ischaemic injury that CT underestimates, and demonstrates the ligamentous and cord injury that changes both prognosis and the forensic picture. It usually needs sedation or anaesthesia, which is exactly why it is not the study for the drowsy or obtunded child in the acute minutes.

Head imaging is performed alongside the survey in any child with neurological signs or a reduced conscious level, and in infants regardless of conscious level — the fact only makes the first of those explicit, and its absence never argues against imaging the head.
The safeguarding process does not change: the request still belongs inside an agreed child protection pathway, and everything produced remains potential evidence.

Infant — head imaging is part of the investigation, not a response to a sign

Role	Study & protocol	Why this answers the question
First line	CT Head CT Head — Unenhanced	In an infant with suspected physical abuse the head is imaged as part of the investigation, whatever the conscious level. Abusive head trauma at this age is commonly occult — no seizure, no drowsiness, sometimes nothing but an unexplained fracture or a poorly feeding baby — so waiting for a neurological sign selects out precisely the children in whom the finding is still silent and still treatable. Unenhanced CT detects acute extra-axial haemorrhage and skull fractures in minutes, without sedation, and it is the study that changes immediate management. It is performed alongside the skeletal survey rather than after it: the survey changes the safeguarding picture over the following days, the head scan changes what happens to this baby today, and a request that has already asked for the urgent head CT must not be sent back to do the survey first.
First line	Skeletal survey Skeletal survey — standard prescribed series	The prescribed survey is equally endorsed and runs alongside the head scan: the injuries with the highest specificity for inflicted trauma — classic metaphyseal lesions and posteromedial rib fractures — are small, subtle and clinically silent, and only dedicated, individually collimated, correctly exposed views of each region resolve them. Under two is where the yield is highest and where the series is prescribed rather than tailored to where the child is sore. It is followed by a repeat survey at around 11 to 14 days, booked when this one is booked.
Problem solving	MRI Brain MRI Brain — routine unenhanced	MRI of the brain, and where indicated the whole spine, follows the CT rather than replacing it — typically within the first few days: it dates collections more reliably, shows the parenchymal and hypoxic-ischaemic injury that CT underestimates, and demonstrates the ligamentous and cord injury that changes both prognosis and the forensic picture. It usually needs sedation or anaesthesia, which is why it is planned rather than done in the acute minutes.

Nothing here is conditional on a neurological sign. The absence of one in an infant is not evidence against intracranial injury, and it is the commonest reason abusive head trauma is missed at first presentation.
The safeguarding process is unchanged: the request belongs inside an agreed child protection pathway with a named paediatrician, and everything produced is potential evidence.

Children

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	Skeletal survey Skeletal survey — standard prescribed series	The full radiographic skeletal survey is the core investigation because the injuries with the highest specificity for inflicted trauma — classic metaphyseal lesions and posteromedial rib fractures — are small, subtle and frequently clinically silent. Only dedicated, individually collimated, correctly exposed views of each region resolve them, which is why the series is prescribed rather than tailored to where the child is sore.
Second line	CT Head CT Head — Unenhanced	Unenhanced CT of the head is performed alongside the survey in infants and in any child with neurological signs or a reduced conscious level: it detects acute extra-axial haemorrhage and skull fractures quickly and without sedation, and it is the study that changes immediate management. The dose is justified by the severity of what it excludes.
Problem solving	MRI Brain MRI Brain — routine unenhanced	MRI of the brain, and where indicated the spine, follows CT: it dates collections more reliably, shows parenchymal and hypoxic-ischaemic injury that CT underestimates, and demonstrates the ligamentous and cord injury that changes both prognosis and the forensic picture. It usually needs sedation or anaesthesia, so it is planned rather than done in the acute minutes.

The follow-up survey at around 11 to 14 days is part of the investigation, not an optional extra, and should be booked at the time of the first study.

Pitfalls

Performing a limited set of films of the injured limb only. That is not a skeletal survey and it does not answer the safeguarding question.
Accepting a single whole-body exposure; the resolution is inadequate for the injuries that matter most.
Omitting the follow-up survey, and so missing the rib and metaphyseal fractures that only become visible as they heal.
Reporting a fracture as "consistent with abuse" in isolation. Radiology contributes specificity and dating; the determination is multi-agency, and the report should be written accordingly.
Overlooking metabolic and skeletal dysplasia mimics — the differential belongs in the report rather than only in the discussion.
Treating an out-of-hours request as routine when there is an acute clinical concern; the head imaging in particular may be urgent even when the survey is not.
Waiting for a neurological sign before imaging an infant’s head. Abusive head trauma under one is frequently silent — no seizure, no drowsiness, sometimes nothing but an unexplained fracture — so a normal conscious level selects out exactly the babies in whom the collection is still occult. The head CT is part of the investigation at this age, not a response to a sign.
Putting the skeletal survey in front of an urgent head CT. The survey changes the safeguarding picture over days; the head scan changes what happens to the child in the next hour, and it takes minutes and no sedation.
Filing the finding instead of raising it. An unexplained fracture or an unexpected extra-axial collection seen on any study is a same-day conversation with the treating clinician and the named safeguarding lead — the duty is the radiologist’s own and does not depend on the request having mentioned abuse.

Priors — what to pull first

Search for previous attendances and imaging across every site the child may have visited, including other hospitals: a pattern of previous injuries is often the most important finding of all.
Previous imaging of siblings may be relevant and is usually addressed within the safeguarding process rather than by radiology alone.

What makes a good request

The request should come from a senior paediatrician within an agreed child protection process, and the examination is normally performed in working hours by radiographers experienced in the technique, with a clear explanation to those with parental responsibility.
The survey is a defined series of dedicated, well-collimated views of the whole skeleton, including oblique views of the ribs. A single whole-body image — a "babygram" — is not an acceptable substitute: it lacks the resolution to show the classic metaphyseal and rib injuries.
A follow-up skeletal survey at about 11 to 14 days is part of the standard investigation, because periosteal reaction and callus make injuries visible that were occult on the first study.
Everything produced becomes potential evidence. Accurate labelling, complete documentation and a report to the agreed standard — in many services double-reported — matter as much as the diagnosis.
The follow-up survey at about 11 to 14 days is not optional and not a repeat of a negative test. Periosteal reaction and callus make rib and metaphyseal injuries visible that were genuinely invisible at presentation, and they date them. It is booked at the same time as the first survey, before anyone leaves the department, because the commonest reason it is not done is that nobody owned it.
The safeguarding duty sits with the radiologist independently of who sent the request. A radiologist who identifies an unexplained fracture, a classic metaphyseal lesion, multiple fractures of different ages or an unexpected intracranial collection — on ANY study, including one requested for something else entirely — must raise it the same day with the responsible clinician and the named safeguarding lead, and record that they did. That duty is not discharged by a report filed into a system, it is not conditional on the referrer having used the word "safeguarding", and it does not wait for the survey. Equally, radiology contributes findings and their dating; the determination of abuse is a multi-agency one.

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

CT Head — Unenhanced Skeletal survey — standard prescribed series MRI Brain — routine unenhanced

Confirm locally

Skeletal survey — standard prescribed series: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.