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.