Purpose or Case Report: Prior research describing risk of physical abuse in children with rib fractures has included children whose rib fractures were incidentally identified in the context of an abuse evaluation. In our practice, the child in whom a rib fracture is the first presenting injury can be a diagnostic challenge, and less is known about this population. Our objectives were to determine the prevalence of 1) additional injuries concerning for abuse, 2) diagnosis of abuse and 3) a report to Child Protective Services (CPS) among children <60 months presenting with rib fractures or with rib fractures identified incidentally during evaluation of a chief complaint unrelated to abuse.
Methods & Materials: We conducted a retrospective study of children <60 months with rib fractures at a tertiary children’s hospital from 2007-2018. Children in motor vehicle accidents, hospitalized following birth, known metabolic bone disease, or whose rib fractures were identified incidentally during an abuse evaluation were excluded. We limited our population to children in whom rib fractures were the presenting injury. Demographic and clinical information was abstracted from the records. The primary outcomes of interest were prevalence of additional injuries, a diagnosis of abuse, and a report to CPS. Associations between patient demographic and clinical characteristics and the outcomes of interest were examined using chi square or fisher exact tests.
Results: Of 67 subjects, 87% were <12 months, 25% had a single rib fracture, 60% had only chronic rib fractures, and 12% had only acute fractures. Additional injuries concerning for abuse were identified in 60%, including head injuries (31%), non-rib fractures (33%), spine injuries (7%), and cutaneous injuries (18%). After applying a standardized scale, 58% were classified as definite/likely abuse. Posterior rib fractures, multiple rib fractures, rib fractures in multiple planes, and rib fractures of multiple ages were all associated with presence of additional injuries and classification as definite/likely abuse (all P<0.05). Age <12 months was associated with classification of definite/likely abuse (P<0.05). African American race, multiple rib fractures, fractures in multiple stages of healing, and fractures in multiple planes were associated with an increased likelihood of reports to CPS (P<0.05).
Conclusions: The presence of a rib fracture in young children is associated with a high likelihood of additional concerning injuries and should prompt a thorough evaluation for physical abuse.