Rib Fractures In Infants Research Articles

Rib fractures in infancy, case-series and register case-control study from Sweden.

To assess cases with rib fractures in infants under observation for or with an abuse diagnosis, and to compare risk factors with that in infants with fractures but no abuse diagnosis. Design was case-series and register case-control of infants (aged <1 year) with rib fractures. Data was clinical records for the case-series (n=26) and from national health registers for the case-controls (n=28 and n=31). Outcome measures were maternal and perinatal characteristics, reasons for appointment, examination, diagnoses, blood tests, and radiologic findings. The case-series had a median age of 70days. A majority were detected through a skeletal survey for abuse investigation. Sixteen were boys, three were preterm and six were small-for-gestational age. Three carers had noticed popping sound from the chest; no infants showed signs of pain at physical examination. Mean number of fractures was 4.2, and 24 had callus. Bone mineralisation was scarcely reported. Metabolic panel was not uniformly analysed. The register case-control had a median age of 76days, sharing risk factors such as maternal overweight/obesity, male sex, prematurity, and being small-for-gestational age. Cases more often had subdural haemorrhage, retinal haemorrhage, or long-bone fractures, controls more often had neonatal morbidity, respiratory infection, or a fall accident. Detection of fracture at time of a major surgery (n=6) and rickets/vitamin D deficiency (n=5) appeared in both groups, but was delayed among the cases. Rib fractures in young infants, diagnosed as abuse, are usually asymptomatic and healing. A substantial proportion had metabolic risk factors, suggesting false positive cases.

Cardiopulmonary resuscitation (CPR)-related posterior rib fractures in neonates and infants following recommended changes in CPR techniques

Posterior rib fractures are highly indicative of non-accidental trauma (NAT) in infants. Since 2000, the “two-thumbs” technique for cardiopulmonary resuscitation (CPR) of newborns and infants has been recommended by the American Heart Association (AHA). This technique is similar to the grip on an infant's thorax while shaking. Is it possible that posterior rib fractures in newborns and infants could be caused by the “two-thumbs” technique? Using computerized databases from three German children's hospitals, we identified all infants less than 12 months old who underwent professional CPR within a 10-year period. We included all infants with anterior–posterior chest radiographs taken after CPR. Exclusion criteria were sternotomy, osteopenia, various other bone diseases and NAT. The radiographs were independently reviewed by the Chief of Pediatric Radiology (MB) and a Senior Pediatrician, Head of the local Child Protection Team (IF). Eighty infants with 546 chest radiographs were identified, and 50 of those infants underwent CPR immediately after birth. Data concerning the length of CPR was available for 41 infants. The mean length of CPR was 11min (range: 1–180min, median: 3min). On average, there were seven radiographs per infant. A total of 39 infants had a follow-up radiograph after at least 10 days. No rib fracture was visible on any chest X-ray. The results of this study suggest rib fracture after the use of the “two-thumbs” CPR technique is uncommon. Thus, there should be careful consideration of abuse when these fractures are identified, regardless of whether CPR was performed and what technique used. The discovery of rib fractures in an infant who has undergone CPR without underlying bone disease or major trauma warrants a full child protection investigation.

Retrospective evaluation and dating of non-accidental rib fractures in infants

To describe the sequential appearance of healing rib fractures on initial and follow-up radiographs using published guidelines in approximating the age of rib fractures in infants with the aim of establishing a more objective method of dating rib fractures by measuring the thickness of the callous formation. This was a retrospective analysis of initial and follow-up digital skeletal surveys of infants less than 12 months of age performed between January 2008 and January 2012 at the University of California Davis Children's Hospital. Six radiological features of rib fractures evaluating the appearance of the callous formation (C stage) and fracture line (F stage) were assessed. Patients with osteogenesis imperfecta, known vitamin D deficiency, and skeletal or metabolic dysplasia were not included in the study. Thereafter, callous thickness was measured and recorded for each stage. Sixteen infants (age range 1-11 months, seven males and nine females) with 23 rib fractures were analysed. The thickness of the callous formation follows a predictable pattern advancing one stage after a 2-week follow-up with progressive callous thickening starting from stage 2, peaks at around stage 4, and then tapers and remodels until it almost disappears when the fracture is healed at stage 6. It appears that rib fractures in infants follow a predictable pattern of healing. Measuring the thickness of the callous formation is a more objective way of guiding the radiologist in estimating the age of the fracture.

How many rib fractures are we missing in children who die without a follow-up skeletal survey?

Purpose: Accepted UK policy for imaging in suspected non-accidental injury (NAI) includes follow-up 3-view chest radiographs two weeks after the initial skeletal survey. If follow-up radiographs are not obtained, then rib fractures may be missed. The purpose of this study was to search for occult rib fractures in infants who arrived to hospital dead or who died in the two week interval period following a skeletal survey for alleged NAI.

High-Impact Trauma Causing Multiple Posteromedial Rib Fractures in a Child

Rib fractures in infants and young children are highly associated with abuse. Fractures near the costovertebral junction carry a high specificity for abuse because they result from excessive anteroposterior chest compression, which may occur when a child is gripped around the chest by an assailant. This results in excessive levering of the posterior ribs over the vertebral transverse processes, resulting in fracture near the rib head or neck. We describe a young child involved in a motor vehicle collision who sustained multiple posteromedial and lateral rib fractures in identical locations to those found in victims of abuse. In this patient, the presumed mechanism of injury was consistent with the compressive forces that cause rib fractures in abused infants and young children. This case illustrates how a high-impact traumatic event may cause rib fractures that would otherwise point strongly to abuse.

Increased incidence of CPR-related rib fractures in infants—Is it related to changes in CPR technique?

Objective A recent increase in the number of infants presenting at autopsy with rib fractures associated with cardio-pulmonary resuscitation (CPR) precipitated a study to determine whether such a phenomenon was related to recent revision of paediatric resuscitation guidelines. Methods We conducted a review of autopsy reports from 1997 to 2008 on 571 infants who had CPR performed prior to death. Results Analysis of the study population revealed CPR-related rib fractures in 19 infants (3.3%), 14 of whom died in the 2006–2008 period. The difference in annual frequency of CPR-related fractures between the periods before and after revision of paediatric CPR guidelines was statistically highly significant. Conclusions The findings indicate that CPR-associated rib fractures have become more frequent in infants since changes in CPR techniques were introduced in 2005. This has important implications for both clinicians and pathologists in their assessment of rib fractures in this patient population.

Two-Handed Cardiopulmonary Resuscitation Can Cause Rib Fractures in Infants

The discovery of acute rib fractures in deceased infants and young children can be unsettling. Although significant injuries may occur subsequent to resuscitative efforts in adults, it is well documented that such injuries are rare in much younger individuals. In particular, it is considered exceptional for rib fractures to follow cardiopulmonary resuscitation (CPR) on an infant; thus, some pathologists will consider such a discovery to be evidence of abuse. However, little is known about what, if any, injuries might occur subsequent to the delivery of "2-handed" CPR. Five unrelated, nonsequential cases of infant death are reported where multiple acute anterolateral rib arc fractures followed 2-handed CPR delivered by trained medical personnel.

Acute rib fracture diagnosis in an infant by US: a matter of child protection

Rib fractures in infants and children are highly specific for inflicted injury in the absence of a major accidental injury or underlying bone disorder. We present a 9-week-old infant diagnosed with an acute rib fracture by US at the site where physicians palpated chest wall crepitus when no rib fractures had been visualized on the skeletal survey, including oblique views of the ribs. Based on the US diagnosis of the acute rib fracture the infant was taken into protective custody. Follow-up skeletal survey 2 weeks later revealed healing fractures of the left 6th and 7th posterolateral ribs and right 7th, 8th and 9th anterolateral ribs. We were unable to locate previous reports describing the diagnosis of rib fractures in infants by US.

How common are rib fractures in extremely low birth weight preterm infants?

Background:This study was prompted by incidental finding of healing rib fractures on chest radiographs of ex-preterm born infants, who were admitted to hospital with acute respiratory illnesses within a few...

Rib Fractures in Infants Due to Cardiopulmonary Resuscitation Efforts

Although it is widely known that adults may sustain fractures of the anterior and/or lateral aspects of the ribs due to cardiopulmonary resuscitation (CPR) efforts, relatively little is written about the generation of CPR-related rib fractures in the infant age range. In a series of 70 consecutive autopsies in infants ranging in age from 2 weeks to 8 months, with no history or indications of injury, the parietal pleura of the thoracic cage was stripped and the ribs carefully examined for fracture. Subtle fractures of the anterolateral aspects of the ribs were discovered in 8 (11%) of the 70 cases. In 7 of the 8 cases, multiple ribs were fractured (ranging up to 10 rib fractures), and in 5 of these cases, the rib fractures were bilateral. All of the rib fractures were subtle, had little if any associated blood extravasation, and would have been easily missed had the parietal pleura not been stripped. These anterolateral rib fractures in infants are the likely correlate of anterolateral rib fractures that are not uncommonly seen in the adult population, resulting from resuscitation efforts. The rib fractures are subtle and may not be identified unless the parietal pleura is stripped.

Fractures costales au cours des bronchiolites aiguës virales : à propos de 2 cas

The 2000 French consensus conference for acute viral bronchiolitis management underlined the fundamental role of chest physiotherapy. According to Chalumeau and al., rib fractures were found out in 1/1000 children hospitalized for bronchiolitis or pneumonia. However, such complication of chest physiotherapy is exceptional. We report 2 cases with third to sixth lateral rib fractures after chest physiotherapy in infants with bronchiolitis. Despite the rarity of these complications, clinicians must keep in mind this etiology while facing rib fractures in infants.

Rib fractures after chest physiotherapy for bronchiolitis or pneumonia in infants.

The reported causes of rib fractures in infants are: child abuse, accidental injury, cardiopulmonary resuscitation, bone fragility, birth trauma and severe cough. To report chest physiotherapy (CPT) as a new cause of rib fractures in five infants. We retrospectively identified all infants with rib fractures after CPT for bronchiolitis or pneumonia over a 4-year period in two paediatric and one paediatric radiology units in three university hospitals in Paris. Five boys were identified. Their median age was 3 months. None had any other potential cause of rib fractures. The indication for CPT was bronchiolitis in four cases and pneumonia in one. The median number of rib fractures was four (range 1-5). Fractures were located between the 3rd and 8th ribs; they were lateral in four patients and posterior in one; they were unilateral in four patients and bilateral in one. Evolution was favourable in all cases. The prevalence of rib fractures after CPT during the study period was estimated at 1 in 1,000 infants hospitalised for bronchiolitis or pneumonia. CPT should be considered a potential, but very rare cause of rib fractures in infants. It can be of clinical relevance when rib fractures are the only feature suggestive of child abuse.

Cause and clinical characteristics of rib fractures in infants.

Rib fractures are uncommon in infancy and, when diagnosed, often raise the suspicion of child abuse. However, the prevalence of other causes of rib fractures has not been well defined. The purpose of this study was to determine the causes and clinical presentations of rib fractures in infants <12 months old. Retrospectively, we identified all infants with rib fractures under 12 months old over a 3-year period using computerized databases at the Children's Hospital Medical Center in Cincinnati, Ohio and at the Children's Hospital, Winnipeg, Manitoba, Canada. Data extracted from the individual patient charts included: age, sex, chief complaint, number and location of rib fractures, associated injuries, birth history, history of cardiopulmonary resuscitation, and any evidence of bone dysplasia. After the chart review and a review of the radiographs by a pediatric radiologist, all fractures were determined to be attributable to one of the following causes: child abuse, birth injury, bone fragility, or accidental trauma. A determination of abuse was made when there were other injuries indicative of abuse, there was no clinical or radiographic evidence of bone fragility, there was a confession of abuse, when no reasonable history of trauma was provided, or when the history was not plausible to explain the rib fractures. Standard practice at these hospitals involves obtaining skeletal surveys on all children <2 years old when abuse is suspected. The child abuse team, which consists of physicians, nurses, and social workers, conducts these investigations and works closely with police in evaluating these children. Thirty-nine infants with rib fractures were identified. Thirty-two (82%) were caused by child abuse. Three (7. 7%) were attributable to accidental injuries, 1 (2.6%) was secondary to birth trauma, and 3 (7.7%) were attributable to bone fragility. All 3 infants with fractures from accidental injury had sustained notable trauma (a motor vehicle collision, a forceful direct blow, and a fall from a height). Of the 3 infants with fractures secondary to bone fragility, 1 infant had osteogenesis imperfecta, 1 infant had rickets, and 1 infant, who was born at 23 weeks' gestation, had fragile bones attributable to prematurity. Most rib fractures in infants are caused by child abuse. Although much less common, rib fractures can also occur after serious accidental injuries, birth trauma, or secondary to bone fragility. A thorough clinical and imaging evaluation is mandatory.

Cardiopulmonary resuscitation and rib fractures in infants: Spevak MR, Kleinman, PK, Belanger PL, et al. JAMA. 1994;272:617-8

Cardiopulmonary resuscitation and rib fractures in infants: Spevak MR, Kleinman, PK, Belanger PL, et al. JAMA. 1994;272:617-8

Cardiopulmonary resuscitation not a likely cause of rib fractures in infants

Cardiopulmonary resuscitation not a likely cause of rib fractures in infants

Cardiopulmonary Resuscitation and Rib Fractures in Infants

To determine the incidence of rib fractures visible at autopsy or with postmortem radiographs after cardiopulmonary resuscitation (CPR) in infants younger than 1 year. Retrospective review. Medical examiner's office in a county consisting of a medium-sized city, towns, and rural areas. Ninety-one infants (56 males, 35 females; mean age, 2.4 months; age range, 26 hours to 8.5 months) without evidence of child abuse who had undergone CPR before death. Medical records, skeletal surveys, and autopsy results were reviewed. No patient had rib fractures. Cardiopulmonary resuscitation is unlikely to cause rib fractures in infants.