Neonatal rib fracture: birth trauma or child abuse?

Journal of Family Practice, Nov, 1989 by Peter J. Rizzolo, Peter R. Coleman

Levine et al(4) retrospectively studied 13,870 singleton consecutive live births and assessed risk factors associated with fractures and other injuries. That fractured ribs were not reported in this large series would suggest either that a rib fracture is an infrequent occurrence or that it is often missed. Thomas5 reviewed rib fractures in infants under I year of age during the period 1969 to 1975. Of over 10,000 chest roentgenograms reviewed, he identified 25 infants with evidence of one or more rib fractures. These included one newborn and one infant at 3 weeks of age. The infant with fracture at birth had osteogenesis imperfecta congenita and died at 3 days. The infant with rib fracture at 3 weeks was a full-term baby weighing 5686 g and was delivered by mid-forceps.

Levine et al identified risk factors associated with fractured clavicle. One might also speculate those same factors being predictive of potential rib fracture. Table I shows the risk factors identified in the infants with fractured clavicles. A score of 5 or greater predicted a fracture in greater than 50% of the injured group. The delivery described in this paper would have a total score of 7, resulting in a greater than 50% chance of a fracture if the risk factor scale of Levine et al were applied.

There are numerous reports of fractured ribs as a result of child abuse. Leonidas(6 ) writes that fractured ribs are the third most frequent skeletal injury in battered children. The authors could find no reports that described abuse in the first week of life. In addition, almost all children with bone injuries from child abuse have other associated injuries. CONCLUSIONS A newborn infant was discovered to have five fractured ribs 9 hours after a vacuum-assisted delivery and moderate shoulder dystocia. The diagnosis of child abuse was seriously considered, but little evidence was found to support this explanation of the injury despite the presence of several child-abuse risk factors.(7-9) The mother's interactions with the child, as observed by nursing staff, medical staff, and social service personnel, were considered to be appropriate. That the child's subsequent development over the first year of life showed normal physical and psychological growth also argues against neonatal child abuse.

The injury is thought to have occurred during the delivery and was missed on the initial examination. The mechanical pressure exerted on the left side of the chest during the upward flexion of the body against the symphysis pubis is the probable mechanism of this trauma. In circumstances consistent with the risk profile as described by Levine et al (Table l)-that is, infant weight greater than 4000 g, shoulder dystocia, and mid-forceps delivery the authors suggest that a careful search for rib fracture may reveal that such an injury is not so rare as the literature would suggest.

In addition to the customary auscultation of the lungs, careful palpation of the ribs looking for evidence of crepitation would probably represent an adequate initial screening measure to rule out rib fracture. Chest x-ray examination is not recommended unless there is respiratory distress or clinical evidence on the physical examination of possible rib fracture. References 1 .Cumming WA: Neonatal skeletal fractures. Birth trauma or child