A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / The objective of this project was to review skeletal survey reports and examine the differences in reporting of non-accidental trauma in patients with similar radiological findings. The overall purpose of this project is to develop a standardized reporting system for radiological findings suspicious for non-accidental trauma. Ten years’ worth of skeletal survey reports were obtained on over 1,500 pediatric patients. These reports were individually reviewed and their findings were categorized in a table separating findings suspicious for non-accidental trauma. After data collection, analysis was completed to inspect the consistency of reports amongst studies with similar fractures specifying non-accidental trauma. The comparison was made between reports containing long bone fractures, metaphyseal corner fractures, rib fractures, or any combination of these. It was concluded that there are inconsistencies in reporting of non-accidental trauma in reports with similar patterns of these fractures. We propose a Skeletal Survey – Reporting and Data System (SS-RADS) score which will help radiologist standardize their reporting methods for more consistent interpretations and clinical outcomes.

Background: Non-accidental Trauma (NAT) is a major cause of morbidity and mortality in children. Children less than 2 years old are at greater risk of NAT than older children. A skeletal survey is a series of X-rays of all the bones in the body, or at least the axial skeleton and the large cortical bones used to identify NAT in children. In this observational study, we examined the association between a child’s age, frequency of positive skeletal surveys, and the types of injuries discovered in pediatric patients undergoing a trauma work-up. Methods: The study sample consisted of all pediatric trauma patients ≤3 years old who had skeletal surveys performed at a single tertiary care center in Central Massachusetts between 2005 and 2015. Patients were divided into two age groups: ≤6months old (n=98) and >6months old (n=86). The utilization of a skeletal survey, frequency of confirmed NAT, and injuries were compared between these 2 age groups. Results: The average age of the sample was 8.4 months, 56.0% were boys, and 62.5% were Caucasian. A positive skeletal survey was found in 14.3% of patients ≤6months old and 18.6% of patients >6months old (p=0.43). The most common fractures identified were long bone (50.0%), torso (30.4%), and skull (13.0%). Similar frequencies of NAT were observed between those less than and older than 6 months (58.2% vs. 57.0%). Head computed tomography (CT) scans were performed in the majority (95.9%) of patients ≤6 months old while in only 66.3% of patients > 6 months old (p < 0.01). Conclusions: Skeletal surveys identify injuries at comparable rates in pediatric trauma patients regardless of age. Advanced imaging differs in younger and older pediatric trauma patients undergoing skeletal survey.

Bakgrund: Trots kriminalisering av barnaga är barnmisshandel förekommande, vilket påträffas i alla samhällsklasser och miljöer. Mörkertalet för misshandel av barn är stort vilket kräver rätta kunskaper och förmågor för att efterfölja den lagstadgade anmälningsplikten för vård, skola och omsorg. Syfte: Syftet med studien är att få en djupare förståelse om röntgensjuksköterskans kunskaper för att upptäcka fysisk misshandel av barn under tre år inom Bild- och funktionsmedicinska avdelningar. Metod: En kvalitativ studie baserad på semistrukturerade intervjuer med fyra legitimerade röntgensjuksköterskor, verksamma på två större universitetssjukhus i mellersta Sverige. Erhållet datamaterial analyserades med den induktiva kategoriseringsansatsen. Resultat: I resultatet framkom olikheter i röntgensjuksköterskans förmåga att upptäcka barnmisshandel. Att röntgensjuksköterskan är medveten om anmälningsplikten framkom tydligt, men det individuella ansvaret att upptäcka och agera på en röntgenavdelning varierade. Informanterna kunde notera kliniska kännetecken vilket grundar sig på tidigare erfarenheter utifrån utredningar av fysisk misshandel samt dess yrkesroll att kunna bedöma bildtagningens kvalité baserat på verksamhetens riktlinjer. I det personliga bemötandet mellan barn, föräldrar och vårdnadshavare uppkom brister vilket speglar sig i dess tidigare teoretiska kunskaper från grundutbildning till interna utbildningar. Ingen av deltagarna anmälde själva till socialstyrelsen vid subtila fall utan lämnade över ansvaret till överordnad. Slutsats: Röntgensjuksköterskorna är väl medvetna om plikten att anmäla barnmisshandel men upplever svårigheter att upptäcka barn som far illa, såsom att uppskatta sin individuella betydelse i vårdkedjan. Studien är användbar och kan replikeras för vidare forskningsmöjligheter. / Background: Although, all forms of child abuse are regarded as a crime it still happening today, independently of social class and environmental area. Since the unrecorded number of child abuse is high, it requires qualified and specific abilities in order to uphold the statutory obligation to report. Aim: The aim of this research is within radiology departments to acquire a deeper understanding of the radiographer’s role and knowledge in discovering physical abuse of children under three years old. Method: A qualitative study based on semi structured interviews, done with four qualified radiographers, operating in two large university hospitals in central Sweden. The conventional content analysis approach is used to analyze the documented material. Results: The result is showing differences in the radiographer’s ability in identifying child abuse. The radiographers are aware of their role in reporting any abuse of a child. However, the individual responsibility to understand the signs and then act upon them vary. The participants were able to notice clinical signs, based on their earlier experience. Although, lack of knowledge was shown in terms of interaction between parents, children and care giver, which is reflecting the radiographers earlier theoretical and internal education. Conclusion: The radiographers are aware of their role of reporting child abuse, although seeing difficulties in identifying physical abuse. Challenges were even shown in understanding their role of expertise and importance in the whole health care chain. The study can be replicated and used for further research possibilities.