Source:

Ruest
S
,
Kanaan
G
,
Moore
JL
, et al
.
The prevalence of rib fractures incidentally identified by chest radiograph among infants and toddlers
.
J Pediatr.
2019
;
204
:
208
213
; doi:
https://doi.org/10.1016/j.jpeds.2018.08.067

Investigators from Hasbro Children’s Hospital, Providence, RI, conducted a retrospective chart review to identify incidental rib fractures in children without known antecedent trauma. Children were eligible if they were aged <2 years and had a chest radiograph (CXR) at the study hospital between 2011–2016. Children were excluded if they had a CXR obtained out of concern for accidental or nonaccidental trauma (NAT).

Demographics, final CXR interpretation by the attending radiologist, and medical history and examination findings were obtained from the participant’s chart. The primary outcome was the proportion of incidentally identified rib fractures. Descriptive statistics were used to summarize demographics and clinical characteristics of participants with incidentally identified rib fractures.

There were 9,720 CXRs from 7,530 unique participants included in the analysis. Of the 9,720 CXRs, only 5 (0.05%; 95% CI, 0.02%–0.12%) had incidentally identified rib fractures. The mean age of those with incidentally identified rib fractures was 3.6 months. Four had a history of prematurity. There was concern for NAT in 3, 1 had confirmed NAT, and 1 had objective radiographic findings consistent with osteopenia of prematurity.

The investigators conclude that incidental rib fractures are rare in a general pediatric population without known antecedent trauma and should prompt a workup for NAT.

Dr Doolittle has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

The current investigators address an important medicolegal question, proposed largely by defense lawyers in child abuse cases. Is it possible for a child to have an incidental rib fracture without trauma or abuse? No study has previously been done to address the prevalence of incidental rib fractures. A dedicated prospective study obtaining CXRs in asymptomatic children would be unethical and impractical. Thus, the current investigators pursued a retrospective study by using the large cohort of children affiliated with a tertiary care institution. Appropriately, they excluded children who were already under evaluation for NAT.

The findings were very compelling and support the concept that an incidental rib fracture strongly suggests NAT. Only 5 patients among 7,350 had incidental rib fractures. Of these, 1 had confirmed NAT, with the child dying in the ICU. NAT was strongly considered in 3 other patients. Although 4 patients were born prematurely (2 at <28 weeks’ gestation), only 1 child received a diagnosis of osteopenia of prematurity as the cause of a rib fracture. This child was born at 28 weeks’ gestation, had a known diagnosis of osteopenia of prematurity, and had 2 incidental rib fractures noted during his NICU stay. These same 2 rib fractures were noted on a predischarge CXR. The study included >1,000 preterm infants, those most at risk for metabolic bone disease, and only 1 demonstrated an incidental fracture.

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