The probability of physical abuse (PA) is high in children with occult rib fractures. Other causes include non-intentional trauma, post surgery and cardiopulmonary resuscitation. Bone fragility increases the risk of fractures, namely metabolic bone disease of prematurity (MBDP), osteogenesis imperfecta, rickets and rare metabolic bone diseases.This case series describes 61 children under two years of age with rib fractures and associations with clinical and radiological features and aetiology. There were 20 cases of PA, 11 post surgical and three non-intentional trauma. Two cases had fractures following cardiopulmonary resuscitation, 18 MBDP and one metabolic bone disease. In six cases, the cause remained unknown. The number and distribution of rib fractures and the age of infants did not discriminate between MBDP and PA. Fractures were predominantly posterior, postero-lateral or lateral. All cases of MBDP had a gestational age of 31 weeks or less and birth weight < 1.25 kg. Each child with MBDP had at least one additional risk factor. Chronic lung disease was recorded in seven, prolonged total parenteral nutrition in ten, steroid use in four, furosemide medication in eight and necrotising enterocolitis in three. All PA cases had other associated injuries or signs of neglect.We recommend a comprehensive assessment of infants with occult rib fractures including an examination to exclude associated trauma, a child protection assessment and a full clinical assessment to exclude risk factors for co-existing bone fragility. Copyright KEY PRACTITIONER MESSAGES:• The number and distribution of rib fractures and the age of infants do not discriminate between PA and rib fractures seen in MBDP.• Assessment of infants with occult rib fractures should include an examination to exclude associated trauma, a child protection assessment and a full clinical assessment to exclude risk factors for co-existing bone fragility.KEY WORDS: rib fractures; physical abuse; metabolic bone disease of prematurity; investigation R ib fractures are said to have the highest specificity for physical abuse (PA) of all childhood fractures. A systematic review of the international scientific literature estimated that in the absence of a motor vehicle accident or witnessed trauma, the probability of child abuse in a young child with rib fractures was as high as 71 per cent (Kemp et al., 2008). However, occult (not clinically evident) rib fractures in infants or young children often pose a clinical diagnostic
Background Occult rib fractures in infancy have the highest positive predictive value for physical abuse (PA) of all fractures. However, they often pose a clinical diagnostic dilemma. We describe the differential diagnosis of rib fractures in infancy and propose a diagnostic algorithm. Methods Children under the age of 24 months with rib fractures were identified from radiological databases in three regional centres from 1998 to 2007. Cases were sorted into diagnostic groups and clinical features were compared and analysed using SPSS 18 for Mac OSX. Results 52 children with rib fractures were identified. 17 had confirmed PA (mean age 4.5 months, range 1–15), 3 suffered witnessed trauma (mean age 16.3 months, range 5–24), 11 were post-surgical (mean age 2.7 months, range 0–5) and 21 were unknown cases (mean age 3.16 months, range 1–7) including 17 with presumed metabolic disease of prematurity, 3 children with no risk factors and 1 fracture presumed to be secondary to cardio-pulmonary resuscitation. When the PA and the unknown group were compared, there was no statistical difference in the number (p=0.131), location (p=0.073–0.525) or distribution of fractures and the NAI group were not more likely to suffer bilateral fractures. Furthermore, significantly more children in the unknown group had a gestational age <30 weeks (17/21) and a birth weight <1.25 kg (18/21) (p<0.001). The unknown group were also more likely to be on frusemide (9/21) and have chronic lung disease (5/21) or prolonged total parenteral nutrition (TPN) > 28 days (8/21). Three children had no predisposing factors for metabolic bone disease and PA was excluded after child protection assessment. All had single rib fractures noted on pre-operative CXRs (1 was on frusemide). Conclusions The number, location, distribution and age of infants with rib of fractures are not discriminatory features for PA. A comprehensive assessment of an infant with occult rib fractures should include a child protection assessment and assessment for gestational age <30 weeks, low birth weight, chronic lung disease, frusemide, prolonged TPN and history of CPR. (Risk factors and clinical indicators for OI should be considered but were not illustrated in this case series).
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