Novel classification system of rib fractures observed in infants

Tailored Surgical Stabilization of Rib Fractures Matters More Than the Number of Fractured Ribs

BACKGROUND

Patients sustaining multiple rib fractures have a significant risk of developing morbidity and mortality. More evidence is emerging that the indication of surgical stabilization of rib fractures (SSRF) should expand beyond flail chest. Nevertheless, little is known about factors associated with poor outcomes after surgical fixation. We reviewed patients with rib fractures to further explore the role of SSRF; we matched two groups by propensity score (PS).

METHOD

A comparison of patients with blunt thoracic trauma treated with SSRF between 2010 and 2020 was compared with those who received conservative treatment for rib fractures. Risk factors for poor outcomes were analyzed by multivariate regression analysis.

RESULTS

After tailored SSRF, the number of fractured ribs was not associated with longer ventilator days (p = 0.617), ICU stay (p = 0.478), hospital stay (p = 0.706), and increased nonprocedure-related pulmonary complications (NPRCs) (p = 0.226) despite having experienced much more severe trauma. In the multivariate regression models, lower GCS, delayed surgery, thoracotomy, and flail chest requiring mechanical ventilation were factors associated with prolonged ventilator days. Lower GCS, higher ISS, delayed surgery, and flail chest requiring mechanical ventilation were factors associated with longer ICU stays. Lower GCS and older age were factors associated with increased NPRCs. In the PS model, NPRCs risk was reduced by SSRF.

CONCLUSIONS

The risk of NPRCs was reduced once ribs were surgically fixed through an algorithmic approach, and poor consciousness and aging were independent risk factors for NPRCs.

Cardiopulmonary Resuscitation Induced Posterior Rib Fractures in Nontraumatic Pediatric Deaths

ABSTRACT

Posterior rib fractures are considered suspicious for nonaccidental injury when observed in infants without significant trauma history or underlying bone disease. The biomechanical mechanism postulated for causing posterior rib fractures is anterior/posterior compression of the chest with posterior levering of the rib head over the transverse process of the vertebra creating a focal area of stress. The recommended "2-thumb" cardiopulmonary resuscitation method involves the administrator placing both thumbs on the sternum of the patient, encircling the chest with the hands, and placing the finger tips lateral to the spine. From this position, the administrator compresses the chest in an anterior/posterior direction by pressing on the sternum. Theoretically, the 2-thumb method should focus all force on the sternum while the back is supported by the fingers limiting posterior levering of the ribs and reducing the risk of posterior rib fractures. However, posterior rib fractures have been found during the autopsy of infants who received 2-thumb cardiopulmonary resuscitation, had no traumatic history, had a nontraumatic cause of death, and had no indication of underlying bone disease. This case study series presents the demographics, birth histories, circumstances surrounding death, and autopsy findings of four such medical examiner cases.

Value of chest CT over skeletal surveys in detection of rib fractures in pediatric patients

Recent literature has raised concerns about the sensitivity and accuracy of radiographs at diagnosing rib fractures. Studies have shown that chest computed tomography (CT) has far greater sensitivity at detecting rib fractures than radiographs. The purpose of this study was to evaluate the sensitivity of skeletal survey (SS) radiographs at diagnosis of rib fractures compared to CT in the pediatric population. This retrospective review included 57 patients who had undergone both a SS and a CT chest or CT chest/abdomen/pelvis within 30 days of each other for the indication of either non-accidental (NAT) or accidental trauma between 2009 and 2017. Images and reports were analyzed by a pediatric radiology fellow for presence/absence of fracture, evidence of healing and location of rib fracture, including rib level, location within the rib (anterior, lateral, and posterior), and side (right versus left). 225 rib fractures were identified in 25 patients on CT. 38 of those fractures were missed on the preceding SS, yielding a miss rate of 17%. Acute fractures were more likely to be missed than chronic or healing fractures (p ≤ 0.01). Location within the rib did not impact rib detection on radiographs. Left-sided rib fractures were not more common in NAT patients, compared to accidental trauma. SS miss approximately 17% of all rib fractures and CT is more sensitive modality in the detection of rib fractures, particularly acute rib fractures, regardless of location. Low-dose Chest CT could be a helpful modality in the work-up of NAT trauma.

Morphology of direct and indirect rib fractures

Rib fractures are a common finding in legal medicine and information on the impact mechanism is relevant for trauma reconstruction. This study focuses on morphological characteristics of rib fractures resulting from direct or indirect force. Fresh human ribs (n = 312) were divided into two groups and broken through local force (direct) and bending (indirect) in anterolateral areas. The ribs were macerated, visually investigated and the results statistically analysed. The indirect fractures showed a significant larger lateral offset of the internal and external fracture ends while the fracture ends of the direct fractures were more often straight, in line. Also, the morphology of the inner and outer fracture edges was significantly related to fracture type. Direct fractures mostly had rough and jagged inner edges (tension side) and straight, smooth outer edges (compression side), whereas indirect fractures more often showed the characteristics vice versa. The results were more convincing in combination and in ribs from persons aged ≤ 75 years at death. In summary, the direct and indirect rib fractures showed significantly different characteristics regarding orientation and offset of the fracture lines and roughness of the inner and outer fracture edges, which can be helpful to distinguish the traumatizing impact mechanisms in forensic autopsy routine.

Characteristics of rib fractures in young abused children

BACKGROUND

The presumed mechanism of rib fractures in abuse is violent grasping of the torso causing anterior-posterior chest compression. We hypothesized an asymmetrical distribution of rib fractures in abused infants given the greater incidence of right-hand dominance within the general population.

OBJECTIVE

The objective of this study was to characterize rib fractures in abused children, particularly sidedness; additionally, we evaluated the sidedness of other abusive skeletal fractures.

MATERIALS AND METHODS

We reviewed medical records from abused children (0-18 months old) with rib fractures. We also retrospectively reviewed their radiographs to determine characteristics of rib fractures (number, side, rib region, level, acuity) and other skeletal fractures (number, side, location), as well as differences in the distribution of rib and other skeletal fractures.

RESULTS

A total of 360 rib fractures were identified on 273 individual ribs involving 78 abused children. Sixty-three children (81%) had multiple rib fractures. There was a significantly greater number of left-side rib fractures (67%) than right-side fractures (P<0.001). Fractures were most often identified in the posterior and lateral regions and mid level of the ribcage (Ribs 5 through 8). Fifty-four percent of subjects had other skeletal fractures; these non-rib fractures were also predominantly on the left side (P=0.006).

CONCLUSION

In our study of abused children, there was a higher incidence of rib fractures in the posterior, lateral and mid-level locations. Additionally, we found a predominance of left-side rib and other skeletal fractures. Further research is needed to understand whether factors such as perpetrator handedness are associated with these unequal distributions of fractures in abused children.

Demystifying the Medical Literature

The published literature is not just the ongoing record of current medical and scientific knowledge; it is a record of the past and can give an eye toward future knowledge. Reading the published literature can give a view of the evolution of knowledge on a particular question, the growth of a discipline, the identification of new diseases, and the refinement of diagnostic tests. The reality is that most busy physicians read only the abstract of an article. The purpose of this article is to place published medical literature into a context and to provide some considerations for critically evaluating articles. This paper will provide historic background of evidence-based medicine and medical publications. Specific strategies for critical literature appraisal are highlights and pitfalls to avoid are outlined.

The Value of Anthropology in Medicolegal Death Investigation of Pediatric Nonaccidental Injury

Forensic anthropologists have made remarkable contributions to the medicolegal investigation of nonaccidental injury in pediatric cases. They have created standard nomenclature for fracture descriptions. Anthropologists have developed novel techniques that increase the sensitivity of the pediatric autopsy. They have performed biomechanical research that enables reconstruction of events surrounding death. Also, anthropology practitioners have developed several reference guides on the subject of nonaccidental injury that are of value to forensic pathologists. These advancements assist forensic pathologists in the accurate classification of cause and manner of death in pediatric cases.

A proposed scheme for classifying pediatric rib head fractures using case examples

Pediatric rib head fractures are typically described as "posterior" or "costovertebral," terms lacking specificity. To resolve this issue, a scheme was developed to describe the location of rib head fractures observed in a pediatric forensic population. The scheme uses three anatomical landmarks, terminus (tip), tubercle, and costovertebral articular surface to divide the rib head into two subregions, costovertebral and costotransverse. Examples of five cases of infants with rib head fractures are presented using this scheme. Forty-eight rib head fractures were observed in these infants with the following frequencies: 56% (three infants) at the terminus; 21% (three infants) in the costovertebral subregion; 21% (one infant) at the costovertebral articular facet; and 2% (one infant) in the costotransverse subregion. Due to the small number of cases assessed, statistical analyses could not be performed; however, the data demonstrate the variation in distribution of pediatric rib head fractures.

The Value of the Pediatric Skeletal Examination in the Autopsy of Children

The pediatric skeletal examination (PSE) is an autopsy technique recommended for pediatric cases suspicious for nonaccidental injury. The technique requires the reflection of the musculature and periosteum of the ribs, clavicles, long bones, and scapulae, and inspection of the bone surfaces and chondro-osseous interfaces. The technique is time consuming, labor intensive and possibly disfiguring. Therefore, the value of the technique must be measured against the cost.

The present study was designed to evaluate the impact of the PSE on the sensitivity of the autopsy. A non-randomized retrospective review of 94 autopsy reports was done. The cause and manner of death for each case was classified as blunt force trauma and homicide. Half of the sample received a PSE during the autopsy and half did not.

The number of rib and long bone fractures noted in the reports was significantly greater in the group that received the PSE. The number of cranial, scapular and clavicular fractures was not significantly different between the two groups. The PSE does not increase the visibility of the neurocranium; therefore, a difference in the number of cranial fractures was not expected. Scapular and clavicular fractures were rare in the study population. The insignificant difference between the two groups may be a reflection of the rarity of the fracture as opposed to the sensitivity of the PSE. The results of the study indicate that the PSE increases the sensitivity of the pediatric autopsy with respect to long bone and rib fractures.

A brief history of fatal child maltreatment and neglect

Child abuse encompasses four major forms of abuse: physical abuse, sexual abuse, psychological abuse, and neglect. The United States retains one of the worst records of child abuse in the industrialized world. It has also been determined that a large portion of these cases are missed and go undocumented in state and federal reporting agencies. In addition, disparate risk factors have been identified for physical abuse and neglect cases, but substance abuse has been found to be a significant factor in all forms of abuse. Fatal child maltreatment and neglect investigations require a multi-pronged and multidisciplinary approach requiring the coordination and information gathering from various agencies. A major difficulty in determining the accidental or non-accidental nature of these cases is that the account surrounding the events of the death of child is acquired from the caretaker. In this review, we outline common diagnostic characteristics and patterns of non-accidental injuries and neglect as a result of nutritional deprivation.