Child Abuse, Rib Fractures

Child abuse: Any act or failure to act by parent/caretaker that causes harm or imminent risk of harm to child

Posterior rib fractures most common & specific for nonaccidental trauma (NAT)

Radiography

• Linear lucency of acute rib fracture often not visible

• Callus/subperiosteal new bone formation may become visible 7-10 days after injury

  • –

    Ranges from indistinct margins & broadening of rib → sharply marginated nodular/bulbous callus

• Rib head fracture may appear fragmented with mixed sclerosis & lucency; often no subperiosteal new bone

Tc-99m MDP bone scan or 18F-NaF PET complementary

• Focal ↑ radiotracer activity within 24 hours

CT not advocated for identifying rib fractures but may be used to evaluate intrathoracic or intraabdominal injury

Indications for initial radiographic skeletal survey

• < 2 years old with suspicion of NAT

• < 5 years old with suspicious fracture

• Suspicion of NAT in any child unable to communicate

Follow-up skeletal survey, typically after 2 weeks, if

• Possible fractures present on initial study

• Normal initial study with persistent suspicion based on clinical or imaging findings

Presentation: Injury inconsistent with history, multiple injuries in various stages of healing, bruising in nonmobile infant, genitalia injury, cigarette burns, other injuries with high specificity for NAT

Majority of rib fractures not suspected on clinical exam

• Overlying bruising in ∼ 9%; ± “clicking” or “popping” sound from back or chest on physical exam

Most common skeletal injury in NAT

• Only radiographic manifestation of NAT in up to 29%

Child abuse: Any act or failure to act by parent/caretaker that causes harm or imminent risk of harm to child

• Also known as nonaccidental trauma or injury (NAT, NAI)