Non Accidental Injury (NAI): Rib Fractures

Chest radiography of a 2-month-old baby shows multiple bilateral rib fractures of different ages. Left-sided rib fractures (arrowheads) appear to have callus formation, while the right sided fractures (arrows) do not. Note right pleural effusion/thickening laterally.

Facts: Fractures in Non-Accidental Injury

• Second most common findings of child abuse after dermatologic findings (bruises, contusions, burns)
• Can be found throughout the whole skeleton
• Likely multiple and in diverse stages of healing
• Long bone fractures are the most common, with some oblique or spiral components (due to torsion force)
• Classic metaphyseal lesions and location of fractures (ie, posterior rib fractures) are more suspicious than others

Rib Fractures in NAI

• Highly predictive of child abuse in the absence of accidental trauma or certain skeletal diseases (e.g., osteogenesis imperfecta), particularly in children less than 3 years old
• In children with rib fractures, the likelihood of NAI decreases with increasing age
• Multiple rib fractures are more likely to be seen in NAI compared to single fractures
• NAI is more likely in the presence of posterior rib fracture

Our case: non-accidental injury with multiple rib fractures in various stages of healing

Reference:

Medina LS, Applegate KE, Blackmore CC. Evidence-based Imaging in Pediatrics, 2010.