Occult Rib Fractures: Defining the Cause

Abstract

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

Suspected Case of Gender Abuse

“…Although clinical exam of the chest does not correlate with her history that she had multiple bruises with the anterior 1st rib fracture on the x-ray that goes along with many case reports of physical abuse due to direct blunt trauma to the chest could be by hand fist or an object [12].…”

The role of the forensic anthropologist in the pediatric autopsy: Interpretations, contributions, and challenges

“…According to relatively recent medical literature, the occurrence of pediatric rib fractures related to CPR is uncommon or rare (Baker, 2014;Franke et al, 2014;Martin, Jones, Maguire, Theobald, & Kemp, 2012;van Wijk et al, 2017). Despite this long standing clinical perspective, there are recent studies recognizing the occurrence of CPR-related rib fractures in pediatric cases (Cosway et al, 2015;Matshes & Lew, 2010;Pinto et al, 2015;Reyes, Somers, Taylor, & Chiasson, 2011). Compared to the posterior and posteromedial rib fractures commonly thought to represent inflicted injury, the fractures from CPR are generally reported to occur on the anterior or lateral rib regions (Collins, Tatum, & Lantz, 2014;Kleinman, 2015;Love et al, 2011;Matshes & Lew, 2010).…”

Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 1: initial considerations and appendicular skeleton

“…All imaging performed for the investigation of suspected II should be assessed for diagnostic quality by the radiologists involved in the subsequent reporting, and if suboptimal should be repeated. Considering the long bones, two orthogonal radiographic views must be obtained of the initial site of clinical concern and other suspicious sites, particularly for suspected or suspicious metaphyseal fractures 7 , diagnosis of which may require coned views of the involved joint(s). In the case of rib fractures, an AP of the chest including the clavicles, in addition to oblique views to show both sides of the chest should be performed.…”

“…The SS should be conducted during normal working hours with a consultant radiologist available to review the images prior to the child leaving the department to determine if additional views are needed. Coned views may also provide further information, particularly when evaluating metaphyseal fractures 7 (Fig 146 2). Table 3 outlines the views required for a complete initial SS 6 .…”