Wood Joanne N, Fakeye Oludolapo, Feudtner Chris, Mondestin Valerie, Localio Russell, Rubin David M
Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;Leonard Davis Institute of Health Economics, and Departments ofPediatrics, and
Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
Pediatrics. 2014 Jul;134(1):45-53. doi: 10.1542/peds.2013-3242. Epub 2014 Jun 16.
To develop guidelines for performing initial skeletal survey (SS) in children <24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties.
Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children <24 months old. After discussion on the initial ratings, panelists re-rated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary.
Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children <12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type.
A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse.
基于现有证据以及来自不同儿科专业的专家的集体判断，制定针对24个月以下骨折儿童进行初次骨骼检查（SS）的指南。
遵循兰德/加州大学洛杉矶分校方法，由13名专家组成的多专业小组运用文献综述的证据并结合自身专业知识，对涉及24个月以下儿童骨折的525个临床场景中进行SS的适宜性进行评分。在对初始评分进行讨论后，小组成员对240个修订后的场景重新评估了SS的适宜性，认为其中191个场景适宜进行SS。然后，小组成员评估了在这191个场景中，哪些场景中SS不仅适宜，而且必要。
小组成员一致认为，在240个评估场景中，191个（80%）场景进行SS“适宜”，在适宜的场景中，175个（92%）场景进行SS“必要”。如果骨折归因于虐待、家庭暴力或被玩具击中，则有必要进行骨骼检查。除少数例外情况外，无创伤史的儿童有必要进行SS。在12个月以下的儿童中，无论骨折类型或报告的病史如何，几乎都有必要进行SS，仅有极少数例外。在12至23个月大的儿童中，是否有必要进行SS取决于骨折类型。
一个多专业小组就多个临床场景达成了共识，这些场景表明骨折幼儿需要进行初次SS，从而综合制定临床指南，有可能减少护理差异并增加对虐待行为的发现。
