Rib Fractures in NonAccidental Trauma

Ashley M. Barrile, MD

Why get images of the chest when

child has another suspicious fracture?
Usually rib fractures NOT suspected clinically
51% of fxs in fatally abused children involve ribs
High mortality rate
Indicate large amount of force used

Posterior rib fractures are highly specifc for

child abuse (especially after ruling out
metabolic disorders, skeletal dysplasias, and
MVAs)
Therefore a skeletal survey of ribs is both
sensitive and specifc for child abuse

Review of Rib Anatomy

Which parts of ribs fracture most

often in cases of NAT?
Mostly rib head and rib neck
(posterior and posterolateral rib)
In study of 63 abused children, 87% of
rib fractures were at the head or the
neck

Fractures of rib head and neck very

rarely from any cause other than
abuse or severe MVA

Posterior Rib Fractures

Disruption of ventral bone cortex at
rib head (short arrows) and rib neck
(long arrows)
Often difficult to visualize on AP view
Only ~50% seen
Important to get CT Chest if highly
suspicious

Mechanism of Injury
Most often due to thoracic compression
Gripping most common cause of compression

Similar force vector and rib motion if infant

slammed on face, thrown face frst at immobile
object
Rib arcs free to move posteriorly, causing excessive
leverage

Rib Fracture Healing

Acute rib fractures, if seen, may be present
seen from time of injury until approx. 5-7 days
Not always visible

Soft Callus seen anywhere from 5-10 days

after injury for infants; 10-14 days for older
children
STILL not always visible

Hard callus 14-21 days (begins) and peaks at

21-42 days in infants
More likely to be visible but still not always on plain
flms

Rib Fractures- Summary

Secondary to AP or
lateral compressive
forces
Squeezing, direct
impact, shaking

Present in 5-25% of
abused children
Posterior &
posterolateral fractures
most common and
highly specifc
Although may occur
anywhere

Rib FracturesSummary
Indicator of severe trauma
due to relative compliance of
rib cage
Associated with high risk of
mortality
Even after vigorous CPR, rib
fracture is uncommon in
children

Up to 50% of all postmortem

fractures are rib fractures
Only 35% of rib fractures are
visible on skeletal survey
Importance of CT chest in cases
where high suspicion of fracture
or any seen on CXR
Formerly, bone scans common
but no longer