Cause and Clinical Characteristics of Rib Fractures in Infants Blake Bulloch, MD, FAAP, FRCPC*; Charles J. Schubert, MD, FAAP*; Patrick D. Brophy, MD, FRCPC§; Neil Johnson, MD‡; Martin H. Reed, MD, FRCPC; and Robert A. Shapiro, MD, FAAP* ABSTRACT. Objective. Rib fractures are uncommon in infancy and, when diagnosed, often raise the suspi- cion 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. Methods. 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 acci- dental 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 prac- tice 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 chil- dren. Results. 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 pre- maturity. Conclusions. 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. Pediatrics 2000;105(4). URL: http://www.pediatrics.org/cgi/content/full/105/4/e48; infants, child abuse, birth trauma, rib fractures. ABBREVIATIONS. CPR, cardiopulmonary resuscitation; OI, os- teogenesis imperfecta; VLBW, very low birth weight. C hild abuse has become widely recognized since the 1960s with a national incidence of nearly 1 million confirmed cases each year. Medical personnel must be skilled in recognizing injuries that are often intentionally inflicted. Rib frac- tures make up between 5% and 27% of all skeletal injuries in abused children. 1 Although rib fractures in infants are relatively uncommon, they are significant when identified because they frequently indicate abuse. Most rib fractures in infants are thought to result from anterior–posterior compression of the chest, often associated with shaking. 2 Because of this mode of injury, rib fractures may be found in asso- ciation with intracranial injuries leading to increased mortality in these children. The clinician’s ability to differentiate abused from nonabused children is dependent on empirically gathered information. Rib fractures are often uncov- ered during the assessment of infants who present to health care providers for a variety of complaints. These complaints include respiratory problems un- related to the fractures, seizures, or other changes in mental status attributable to accompanying intracra- nial injuries. Knowledge regarding clinical features and imaging findings may help to differentiate abused infants from those who are not abused. In addition, there should be familiarity with the preva- lence and presentation of conditions that can be mis- taken for abuse. The objective of this study was to analyze and describe the different causes, radiographic findings, and clinical characteristics in infants with rib frac- tures 12 months old. METHODS We identified all infants 12 months old who had rib fractures identified at 2 hospitals between August 1994 and January 1997. At Children’s Hospital Medical Center in Cincinnati, Ohio, iden- tification was made using the computerized database of the divi- sion of Pediatric Radiology. At Winnipeg Children’s Hospital in Canada, charts of infants with rib fractures were identified from a computerized database using the American College of Radiology index code. All radiograph reports, which included the term rib fracture, were extracted from the databases. The medical charts of the infants identified by these reports were then reviewed. The From the Divisions of *Emergency Medicine and ‡Pediatric Radiology, Children’s Hospital Medical Center, Cincinnati, Ohio; and Departments of §Pediatrics and Radiology, Winnipeg Children’s Hospital, Winnipeg, Manitoba, Canada. Received for publication Mar 27, 1998; accepted Nov 18, 1999. Reprint requests to (B.B.) Winnipeg Children’s Hospital, 840 Sherbrook St, Winnipeg, MB, R3A-1S1, Canada. E-mail: bbulloch@mb.sympatico.ca PEDIATRICS (ISSN 0031 4005). Copyright © 2000 by the American Acad- emy of Pediatrics. http://www.pediatrics.org/cgi/content/full/105/4/e48 PEDIATRICS Vol. 105 No. 4 April 2000 1 of 5 by guest on July 24, 2015 pediatrics.aappublications.org Downloaded from