Skeletal Surveys in Suspected Non- Accidental Injury (NAI)

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This is an official Northern Trust policy and should not be edited in any way Skeletal Surveys in Suspected Non- Accidental Injury (NAI) Reference Number: NHSCT/11/410 Target audience: This protocol

1 This is an official Northern Trust policy and should not be edited in any way Skeletal Surveys in Suspected Non- Accidental Injury (NAI) Reference Number: NHSCT/11/410 Target audience: This protocol is directed at Paediatricians, Radiologists and Radiographers Sources of advice in relation to this document: Dr Mike Ledwith, CD Paeds Dr Myles Nelson, CD Radiology Dr Patricia Higgins, Cons Radiologist Dr Niall MacKenzie, Cons Radiologist Dr Alison Livingstone, Cons Paediatrician Dr Jarlath McAloon, Cons Paediatrician Replaces (if appropriate): N/A Type of Document: Trust Wide Approved by: Policy, Standards and Guidelines Committee Date Approved: 21 April 2011 Date Issued by Policy Unit: 21 June 2011 (Reissued 5 July 2011 due to minor individual name changes) NHSCT Mission Statement To provide for all, the quality of service we expect for our families, and ourselves.

Radiologist Dr Niall MacKenzie, Cons Radiologist Dr Alison Livingstone, Cons Paediatrician Dr Jarlath McAloon, Cons Paediatrician Replaces (if appropriate): N/A Type of Document: Trust Wide Approved

2 Skeletal Surveys in Suspected Non- Accidental Injury (NAI) June 2011

3 Protocol for Requesting and Reporting of Skeletal Surveys in Suspected Non-Accidental Injury (NAI) Introduction to Protocol Paediatric patients in whom non-accidental injury is suspected may require a series of x-rays known as a skeletal survey to outrule old fractures or other bony injury not clinically evident. The requesting of this study requires careful consideration as it should only be carried out in the correct circumstances and must be interpreted by a skilled radiologist with appropriate training and support. Purpose of protocol This protocol is written with child safety and welfare as a priority. The protocol is designed to ensure that skeletal surveys are carried out correctly and interpreted by radiologists with appropriate training and support. It is also designed to ensure that the results of this study are acted upon promptly. Thirdly, the protocol ensures that the information obtained in the study can be safely used in any legal proceedings arising from the suspicion of non-accidental injury. Target audience This protocol is directed at consultant Paediatricians, Radiologists and Radiographers. Legislative compliance This protocol meets all legal requirements and the policies of the Royal College of Radiologists and the Royal College of Paediatrics and Child Health. 1

The requesting of this study requires careful consideration as it should only be carried out in the correct circumstances and must be interpreted by a skilled radiologist with appropriate training

4 Protocol (including responsibilities) Formal consent from a person with parental responsibility should be obtained by a Paediatrician. Responsible individual Consent should be documented in the child s medical notes. Parents/carers must be told that the investigation is to search for other injury or bone disease. All requests for NAI skeletal survey should be referred to X-ray Departments in Antrim (AAH) or Causeway (CAU) Hospitals only. The request form should be completed by Paediatrician and should clearly state that NAI is being considered. Drs. Higgins (AAH) and Mackenzie (CAU) should be informed BEFORE the examination takes place, to ensure that one or other is available for reporting. If neither is available, then the Paediatrician should contact a RBHSC Radiologist to request that they take responsibility for reporting of the survey. Paediatrician Paediatrician NAI skeletal surveys should normally be carried out as routine examinations and not out-of-hours. Every effort will be made to perform these studies during the next working day. Those identified in Target Audience In addition, there must be another professional who is responsible for the child s safety while in the Radiology Department. This would normally be a paediatric nurse or other healthcare professional from the paediatric department. Paediatrician The skeletal survey will be carried out or supervised by a Senior Radiographer. The films will be sent to Dr. Higgins (AAH) or Dr. Mackenzie (CAU) or a RBHSC Paediatric Radiologist for reporting. Until PACS is implemented, this may require taxi transport, organised by the Radiographer. When PACS is implemented, the radiographer will inform the reporting radiologist by telephone to say images are ready for review. Radiographer 2

All requests for NAI skeletal survey should be referred to X-ray Departments in Antrim (AAH) or Causeway (CAU) Hospitals only.

5 Copies of all films should be retained at the referring X-ray Department. Images to be locked on CR system. Radiography Managers - Geraldine McCafferty/ Nikki Armstrong Drs. Higgins/Mackenzie will cross-cover each other where at all possible. If the survey is negative, it will be double-read by the other this is to be organised by themselves. If positive, they will organise a second opinion from RBHSC. In the latter case, the local Radiologist will organise contact and transport of the films. Drs. Higgins/ Mackenzie The report will be conveyed verbally at the earliest opportunity to the referring Paediatrician. This will be provisional and will be after their initial opinion. A written report will follow, also at the earliest opportunity. In due course, there will be a further report from the second Radiologist or RBHSC. Drs. Higgins/ Mackenzie Coned views of any suspicious areas. Repeat views of chest and ribs at 2 weeks. Reporting Radiologist via referring Paediatrician s Secretary Telephone Numbers: Antrim X-ray Reception: Causeway X-ray Reception: RBHSC X-ray Reception:

If positive, they will organise a second opinion from RBHSC. In the latter case, the local Radiologist will organise contact and transport of the films. Drs.

6 Appendix 1: The standard child protection skeletal survey for suspected non-accidental injury. Check that x-ray views have not already been carried out through A&E. Patient ID bands to be moved away from joint area. Grids are not routinely used to image spine, pelvis, skull and abdomen on children under 6 months. Skull: Anterior posterior (AP), lateral, and Townes view (the latter only if clinically indicated). Skull x-rays should be taken with the skeletal survey even if a CT scan has been or will be performed. Chest: AP including the clavicles. Right and left oblique ribs. Abdomen: AP of abdomen including the pelvis and hips. Spine: Lateral, to include L5/S1 junction and spinous processes this may require separate exposures of the cervical, thoracic and thoraco-lumbar regions. If the whole of the spine is not seen in the AP projection on the chest and abdominal radiographs then additional views will be required. Limbs: AP of both upper arms) AP both forearms ) one film AP both femurs ) AP both lower legs ) one film. Good views of ankle and knee essential. PA of hands. DP of feet. 4

Skull: Anterior posterior (AP), lateral, and Townes view (the latter only if clinically indicated).

7 Appendix 2: Consider CT if: Any child who presents with evidence of physical abuse with encephalopathic features or focal neurological signs or haemorrhagic retinopathy. Any child under the age of 1 year where there is evidence of physical abuse. Reference: Royal College of Radiologists / Royal College of Paediatrics and Child Health March

Any child under the age of 1 year where there is evidence of physical abuse.

Standards for Radiological Investigations of Suspected Non-accidental Injury

Standards for Radiological Investigations of Suspected Non-accidental Injury March 2008 The Royal College of Radiologists Royal College of Paediatrics and Child Health Standards for Radiological Investigations