Thirty-four studies met the inclusion criteria (n not reported).
Diagnostic yield and sensitivity of BS and SS.
Five studies reported that BS was more sensitive than SS, and 2 studies that SS was more sensitive than BS.
Fourteen studies reported that either BS or SS alone was inadequate to identify all fractures.
One study reported that SS identified metaphyseal and skull fractures significantly better than BS.
Two studies that used follow-up radiograph noted false-positive findings with BS.
Across 8 studies: BS predominantly missed skull, metaphyseal and epiphyseal fractures, but identified associated soft tissue injury; SS missed rib fractures, perosteal injury and rear fractures of the foot or pelvis. Details of false negatives from the included studies were tabulated.
Repeat SS.
Two studies reported an increased yield with repeat SS; additional injuries identified were metaphyseal, rib, scapula, and vertebral fractures.
Accuracy of different SS views.
One randomised controlled trial showed that the addition of two oblique views to a four-view assessment increased sensitivity by 17% (95% confidence interval: 2, 36, p=0.18) and specificity by 7% (95% confidence interval: 2, 13, p=0.004).
Improved diagnosis has been reported for additional views and close inspection of radiographs of the pelvis (5 studies), hands and feet (3 studies), and spine (4 studies).