Rib Fractures

Get CMERib FractureWe know that children are super flexible and that is a good thing!  Often kids will bend and won’t break!  Unfortunately, there are events that still lead to childhood injuries. Some of these events are unfortunate and accidental (ex, Submersions), while others are sinister and purposeful (ex, Abuse). When we think of injury in children, we often immediately consider head trauma (the leading cause of mortality), but let us not overlook thoracic trauma as it is the second leading cause of mortality in children suffering from trauma. While pulmonary contusions are the the most common intra-thoracic injury, let’s spend a moment contemplating the significance of Rib Fractures.

 

Rib Fractures: Description

  • 4 fracture types have been described. [Love, 2013]
    • Transverse
    • Oblique
    • Buckle
    • Sternal end
  • 4 locations have been described. [Love, 2013]
    • Posterior
    • Posterolateral
    • Anterolateral
    • Anterior
  • Rib fractures occur by 2 possible mechanisms:
    • Anterior-posterior compression (most common)
    • Direct trauma to rib surface

 

Rib Fractures: Age Matters

  • Children have rib fractures less often than adults due to anatomic and structural differences.
  • Rib morphology and orientation changes with age. [Weaver, 2014]
    • Rib cage increases in size and decreases in kyphosis from birth to teen years.
    • Ribs rotate inferiorly also.
    • Ribs increase in roundness and horizontal angle with increased age.
    • These changes influence risk for fracture with increasing age (particularly elderly patients).
  • The thoracic cage is more compliant (more able to deform without fracture) in children.
    • It takes a significant force to cause a rib fracture in a child.
    • The complaint chest wall does not dissipate a force as well, transmitting more of it inward to the underlying organs (see Pulmonary Contusion).

 

Rib Fractures: The Concerns

  • Abuse should always be on your radar!
    • Most rib fractures in infants are caused by child abuse. [Bulloch, 2000]
      • Other etiologies should be considered as well.
      • Ex, Birth Trauma, Rickets, Osteogenesis Imperfecta
    • Abused children have more rib fractures than accidentally injured children. [Darling, 2014]
    • Accidental injuries cause more intrathoracic injuries, likely due to the mechanisms. [Darling, 2014]
    • Lack of intrathoracic injury does not rule out abuse! [Darling, 2014]
    • Concurrent extra-thoracic fractures where more common in abuse cases. [Darling, 2014]
  • Rib fractures are associated with other injuries.
    • Children have higher rates of associated head, thoracic, and solid organ injuries with rib fractures compared to adults. [Kessel, 2014]
    • Rib fractures should be considered a sign of significant, possible multiple, trauma in kids.
  • Mortality increases in a LINEAR fashion for each fractured rib in children. [Rosenberg, 2016]
    • Adult mortality has a steep increase above 6 fractured ribs.
    • In kids, mortality odds worsen with each rib fractured.
      • Mortality increased from 1.79% without rib fracture to 5.81% with one rib fracture.
      • With each rib fracture, mortality rate increased in nearly linear fashion up to 8.23% for 7th rib fractured.

 

Moral of the Morsel

  • Highly consider abuse in children with rib fractures! May even want to consider extra thoracic injuries.
  • Consider rib fractures as a indication of significant impact and trauma! Treat it like a risk factor for other occult injuries.
  • Know that each rib fractured increases a child’s risk of mortality!

 

References

Rosenberg G1, Bryant AK, Davis KA, Schuster KM. No breakpoint for mortality in pediatric rib fractures. J Trauma Acute Care Surg. 2016 Mar;80(3):427-32. PMID: 26713973. [PubMed] [Read by QxMD]

Agnew AM1, Schafman M2, Moorhouse K3, White SE4, Kang YS5. The effect of age on the structural properties of human ribs. J Mech Behav Biomed Mater. 2015 Jan;41:302-14. PMID: 25260951. [PubMed] [Read by QxMD]

Kessel B1, Dagan J2, Swaid F3, Ashkenazi I2, Olsha O4, Peleg K5, Givon A5; Israel Trauma Group, Alfici R2. Rib fractures: comparison of associated injuries between pediatric and adult population. Am J Surg. 2014 Nov;208(5):831-4. PMID: 24832239. [PubMed] [Read by QxMD]

Weaver AA1, Schoell SL, Stitzel JD. Morphometric analysis of variation in the ribs with age and sex. J Anat. 2014 Aug;225(2):246-61. PMID: 24917069. [PubMed] [Read by QxMD]

Marine MB1, Corea D, Steenburg SD, Wanner M, Eckert GJ, Jennings SG, Karmazyn B. Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified? AJR Am J Roentgenol. 2014 Apr;202(4):868-71. PMID: 24660718. [PubMed] [Read by QxMD]

Darling SE1, Done SL, Friedman SD, Feldman KW. Frequency of intrathoracic injuries in children younger than 3 years with rib fractures. Pediatr Radiol. 2014 Oct;44(10):1230-6. PMID: 24771095. [PubMed] [Read by QxMD]

Love JC1, Derrick SM, Wiersema JM, Pinto DC, Greeley C, Donaruma-Kwoh M, Bista B. Novel classification system of rib fractures observed in infants. J Forensic Sci. 2013 Mar;58(2):330-5. PMID: 23406328. [PubMed] [Read by QxMD]

Hamilton NA1, Bucher BT, Keller MS. The significance of first rib fractures in children. J Pediatr Surg. 2011 Jan;46(1):169-72. PMID: 21238660. [PubMed] [Read by QxMD]

Bulloch B1, Schubert CJ, Brophy PD, Johnson N, Reed MH, Shapiro RA. Cause and clinical characteristics of rib fractures in infants. Pediatrics. 2000 Apr;105(4):E48. PMID: 10742369. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. June 4, 2016

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