Rib Fractures: A Case of Abuse in a 6-Month-Old

Answer: This is a case of child abuse.

A 6-month-old girl was brought to the emergency department (ED) of a rural hospital by her mother and father with fever, cough, and irritability. Both parents appeared to be developmentally delayed but acted appropriately under the circumstances.

The child was born prematurely at 34 weeks; she had a long complicated stay in the newborn intensive care unit (NICU). She had required ventilation for several weeks and the parents were certain she had been given “fluid pills” (furosemide) because of lung “problems.” When later questioned, the parents also stated that the child had received CPR on 2 occasions during her stay in the NICU.

The infant’s immunizations were up to date.

The physical examination showed the child to be small for her age. Her heart rate was 155 beats/min; respiratory rate, 48 breaths/min; temperature, 101.3^oF. The child appeared well-hydrated, clean, and free of signs of trauma. She was extremely irritable, however. There was concern about lung “congestion” noted on the ED report. The chest film (Figure) findings were as shown. The ED physician made a diagnosis of pneumonia. Rib fractures were also noted, of which the parents were unaware.

The ED physician recommended admission overnight.

By the following morning, records obtained from the NICU showed there was no history of any fractures at time of discharge 3 months earlier.

The father was very anxious; his anxiety had escalated to the point that he was asked by security to leave the hospital. He was concerned that he was being accused of child abuse. He was under suspicion at this point, but no one had yet approached him or his wife. 

The child had a head CT scan as well as retinal examination. Results of both were normal.

Child Protective Services was consulted; the mother told the social worker how the father had squeezed the baby’s chest when the baby cried. The father confessed to the police later in the day. The mother lost custody of the child for 6 months while she completed parenting classes and the father served prison time for child abuse.

Discussion
Without question, this is the most straightforward case of child abuse involving rib fracture with which I have ever been involved. There was eyewitness testimony and a perpetrator confession within less than 12 hours of the clinical presentation.

Rib fractures suggest abuse and are a lone finding in 29% of skeletal injury cases.¹

Without the father’s confession and the x-ray films from the NICU, this case would have been very difficult to prove. It is commonly accepted that prematurity as well as administration of total parenteral nutrition or furosemide(Drug information on furosemide) all predispose to fractures.² The fact that this child had also received CPR would have been a point of contention as well.³ In similar cases, there are claims that rib fractures are the result of birth fractures becuase of the baby’s size or method of delivery.⁴

References
1. Barsness KA, Cha E-S, Bensard DD, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma. 2003;54:1107-1110.
2. Amir J, Katz K, Grunebaum M, et al. Fractures in premature infants. J Pediatr Orthop. 1988;8:41-44. http://www.ncbi.nlm.nih.gov/pubmed/3121670.
 3. Dolinak D. Rib fractures in infants due to cardiopulmonary resuscitation efforts. Am J Forensic Med Pathol. 2007;28:107-110.
4. Hartmann, RW Jr. Radiological case of the month. Arch Pediatr Adolesc Med. 1997;151:947-948.
5. Bulloch B, Schubert CJ, Brophy PD. Cause and clinical characteristics of rib fractures in infants. Pediatrics. 2000;105:e4-8. http://www.pediatricsdigest.mobi/content/105/4/e48.full.