The Role of Ultrasound in Diagnosing Metaphyseal Fractures in Children Below 18 months old in whom Physical Abuse is Suspected

Abstract

Aim To evaluate the role of ultrasound in diagnosing metaphyseal fractures in children under 18 months of age. Material and Methods A multi-phase methodological approach was adopted, comprising six complementary studies. These included, a systematic review was conducted to determine the accuracy of medical imaging modalities in diagnosing metaphyseal fractures; multicentre observational study of 36 healthy patients under 18 months of age to develop an atlas of the normal appearance of the metaphyses; retrospective assessment of the quality of 538 ultrasound images from the observational study using a previously validated scoring system; prospective multicentre study on the use of ultrasound in suspected cases of child physical abuse; qualitative focus group study to identify solutions to the challenges in recruiting suspected child abuse cases; survey study exploring the role of ultrasound in the diagnosis of metaphyseal fractures in clinical practice worldwide. Results Sensitivity and specificity were 67% and 99% for PET, and 55–61% and 96–97% for ultrasound. The images from the observational study showed no significant differences in the metaphyseal region between age groups. Intra-rater reliability was good (ICC: 0.84–0.89), while inter-rater reliability showed moderate agreement across operator pairs. Only 4 of 74 potential candidates (5%) were recruited. The challenges included parental refusal, the unavailability of paediatricians to obtain consent, and short notice of incoming cases. Several factors may facilitate recruitment, including neutralising the study title, combining clinical and research consent, and support from experts. Survey responses indicated that ultrasound use for diagnosing metaphyseal fractures is limited internationally. Conclusion The limited sample size was due to several challenges including the need for training and expertise and issues of informed consent. Despite those challenges, ultrasound findings confirmed skeletal survey findings. Future studies should investigate potential solutions to these challenges and further explore the role of ultrasound in metaphyseal fracture diagnosis.