Abstract
ObjectivesTo assess the diagnostic performance of chest CT in the detection of rib fractures in children investigated for suspected physical abuse (SPA).MethodsMedline, Web of Science and Cochrane databases were searched from January 1980 to April 2020. The QUADAS-2 tool was used to assess the quality of the eligible English-only studies following which a formal narrative synthesis was constructed. Studies reporting true-positive, false-positive, true-negative, and false-negative results were included in the meta-analysis. Overall sensitivity and specificity of chest CT for rib fracture detection were calculated, irrespective of fracture location, and were pooled using a univariate random-effects meta-analysis. The diagnostic accuracy of specific locations along the rib arc (anterior, lateral or posterior) was assessed separately.ResultsOf 242 identified studies, 4 met the inclusion criteria. Of these, 2 were included in the meta-analysis. Chest CT identified 142 rib fractures compared to 79 detected by initial skeletal survey chest radiographs in live children with SPA. Post-mortem CT (PMCT) has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures when compared to the autopsy reference standard. PMCT has low sensitivity (45%, 21% and 42%) but high specificity (99%, 97% and 99%) at anterior, lateral and posterior rib locations, respectively.ConclusionsChest CT detects more rib fractures than initial skeletal survey chest radiographs in live children with SPA. PMCT has low sensitivity but high specificity for detecting rib fractures in children investigated for SPA.Key Points• PMCT has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures; extrapolation to CT in live children is difficult.• No studies have compared chest CT with the current accepted practice of initial and follow-up skeletal survey chest radiographs in the detection of rib fractures in live children investigated for SPA.
Highlights
Physical child abuse is one of the leading causes of child morbidity and mortality worldwide [1, 2]
No studies have compared chest computed tomography (CT) with the current accepted practice of initial and follow-up skeletal survey chest radiographs in the detection of rib fractures in live children investigated for suspected physical abuse (SPA)
Physical abuse is more common in children aged less than 2 years [5, 6], in particular children less than 12 months, who are typically pre-ambulant or non-ambulant who are unable to localise their pain or communicate a history of injury [6, 7]
Summary
Physical child abuse is one of the leading causes of child morbidity and mortality worldwide [1, 2]. Physical abuse is more common in children aged less than 2 years [5, 6], in particular children less than 12 months, who are typically pre-ambulant (those who will typically go on to walk in the future) or non-ambulant (those who will never walk, e.g. wheelchair-bound) who are unable to localise their pain or communicate a history of injury [6, 7]. Fractures are the second most common finding associated with physical abuse [8]. Rib fractures are strongly associated with physical abuse in infants and young children [9,10,11,12] with positive predictive values (PPVs) of 95% and 66% in children under 3 [13] and 4 years of age [14], respectively. Rib fractures are uncommon following accidental trauma in children under the age of 3 years due to the plastic nature of the thoracic cage in this age group [13, 15]
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