Outcomes of indeterminate fractures identified on skeletal surveys obtained during non-accidental trauma evaluations.

BACKGROUND: Skeletal surveys (SS), a critical component of non-accidental trauma (NAT) evaluations, may have indeterminate findings concerning for a possible fracture. The frequency and clinical impact of these indeterminate fractures is unknown. OBJECTIVES: In children with SS obtained as part of NAT evaluations, 1) determine the prevalence and clinical characteristics of indeterminate fractures, 2) describe frequency and type of follow-up imaging, and 3) ascertain the potential impact of indeterminate fractures. PARTICIPANTS AND SETTING: A single-center, retrospective chart review of children <2 years who underwent an initial SS to evaluate for NAT, between January 2020 and March 2024. METHODS: Descriptive statistics were used to calculate the frequency of indeterminate fractures, clinical characteristics, follow up imaging, and impact. RESULTS: Of 1198 initial SSs, 153 (13%) had at least 1 indeterminate fracture. These 153 SSs identified a total of 254 indeterminate fractures (median = 1, IQR 1-2), frequently classic metaphyseal lesions (25%, 64/254) or rib fractures (25%, 64/254). Most patients (93%, 143/153) underwent at least one clarifying imaging study; more than half (80, 52%) required >24 h for uncertainty resolution. A minority of indeterminate fractures were ultimately confirmed as true fractures (24%, 60/254). Seventy percent (107/153) of patients had concurrent, definitive injury and 55% (84/153) were referred to child protective services. CONCLUSIONS: One in eight SSs identified at least one indeterminate fracture, often a fracture type highly specific for NAT. However, most were not true fractures, suggesting opportunities for improvement in SS workflow given the diagnostic implications.