Pediatric emergency medicine trisk 3718 3718

RIB FRACTURES
Rib fractures secondary to thoracic trauma are far less common in children than
in the adult population. They may occur from either a direct blow to the rib or
compression of the chest in an anterior–posterior direction. In a direct blow to the
rib, the rib will fracture inward and may puncture the pleural cavity, causing a
pneumothorax, or lacerate a blood vessel resulting in a hemothorax. Compression
of the chest wall can cause the lateral portions of the ribs to fracture outward.
Intrathoracic injury is seen less commonly with this type of fracture.
In one study, rib fractures occurred in 32% of all children admitted with
thoracic trauma, with motor vehicle collisions accounting for the largest
proportion of injuries. Single rib fractures did not correlate with the severity of
injury, but as the number of fractures increased, so did the likelihood of
multisystem and intrathoracic injuries. While studies have shown that first rib
fractures are only predictive of intrathoracic injury in the presence of other
concerning symptoms, a higher index of suspicion for intrathoracic injury is
necessary in the presence of a first rib fracture due to force required to injure this
rib in its protected location.
The pediatric patient with a rib fracture may splint and hypoventilate secondary
to pain. Physical examination may reveal point tenderness and crepitus if a
pneumothorax is present. If the patient is stable, then management should focus
on relief of pain, monitoring the respiratory status, and further evaluation for
underlying injury. Wrapping or binding the chest wall is contraindicated because
these measures may impair ventilatory function. Opiates may be required but
should be used with caution because they may also cause respiratory depression.
For patients requiring admission to the hospital, epidural analgesia or intercostal
nerve blocks may be helpful.
Patients with multiple rib fractures should be admitted to the hospital for pain
control, pulmonary physiotherapy, and observation for worsening respiratory
status. Younger children may require admission to rule out child abuse. Prognosis
for isolated rib fractures is excellent, with most healing within 6 weeks without
any permanent disability.

RIB FRACTURES AND CHILD ABUSE
Rib fractures in young children are highly associated with child abuse. In one
study, the positive predictive value of a rib fracture for nonaccidental trauma was
95% in children less than 3 years old; this number increased to 100% when there
was no obvious accidental mechanism provided by the caretaker. Additionally,
posterior rib fractures or fractures at multiple stages of healing in infants and