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Number and location of abusive rib fractures

The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.


  • In one study investigating fractures in young children, rib fractures were the most strongly associated with abuse 8
  • In another study, the most prevalent injuries in the child abuse group following non-bony head injury and skull fractures were rib fractures  10


Multiple rib fractures

  • Abused children had multiple rib fractures 1,2,4-6,13,18 . This included a comparison with children with metabolic bone disease 5
  • Flail chest due to multiple rib fractures in infant physical abuse is reported in one study 9
  • One study reported that the risk of mortality increases with the number of ribs fractured 8


Location of fractures

  • Abusive rib fractures were recorded at any location on the rib and were unilateral or bilateral 2,4,11,13,14,18
  • Anterior fractures were more common in abuse whilst lateral fractures were more common in non-abused children 2,4
  • Seven studies stated that posterior rib fractures were the predominant abusive fracture, detailed breakdown was not given 1-3,7,15-175
    • One study found posterior and postero-lateral rib fractures to be equally common in abuse and metabolic bone disease 5


First rib fractures

Two studies 1,16 report: 

  • Five cases of abusive first rib fractures were recorded 16
  • Predominantly lateral, one posterior. 1,16  Four had no fracture to adjacent bones 16
  • Four had associated neurological injury 16



Costochondral junction fractures

  • Anterior costochondral fractures are described in abuse 1,11
  • They may be difficult to visualise radiographically and can occur with associated abdominal injuries 11


Intrathoracic injury in children with rib fractures

  • One study evaluated intrathoracic injuries in abused and non-abused children less than three years of age with rib fractures.  Accidentally injured children had more intrathoracic injuries than abused 6
  • Those who were accidentally injured showed a significant correlation between number of rib fractures and intrathoracic injury which was not seen in the abused children 6


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  1. Barber I, Perez-Rossello JM, Wilson CR, Kleinman PK. The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatric Radiology. 2015;45(1):69-80 [Pubmed]

  2. Barsness KA, Cha ES, Bensard DD, Calkins CM, Partrick DA, Karrer FM, Strain JD. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. Journal of Trauma - Injury Infection & Critical Care. 2003;54(6):1107-1110 [Pubmed]
  3. Bulloch B, Schubert CJ, Brophy PD, Johnson N, Reed MH, Shapiro RA. Cause and clinical characteristics of rib fractures in infants. Pediatrics. 2000;105(4):E48 [Pubmed]
  4. Cadzow SP, Armstrong KL. Rib fractures in infants: red alert! The clinical features, investigations and child protection outcomes. Journal of Paediatrics and Child Health. 2000;36(4):322-326 [Pubmed]
  5. Cosway B, Mathura N, Mott A, Bredow M, Fraser J, Rawlinson A, Wei C, Thyagarajan M, Harrison S, Kemp A. Occult rib fractures: Defining the cause. Child Abuse Review. 2013. [Early View - Abstract available from Wiley online library]

  6. Darling SE, Done SL, Friedman SD, Feldman KW. Frequency of intrathoracic injuries in children younger than 3 years with rib fractures. Pediatric Radiology. 2014;44(10):1230-1236 [Pubmed]

  7. Feldman KW, Brewer DK. Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics. 1984;73(3):339-342 [Pubmed]
  8. Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. The Journal of Trauma. 1990;30(6):695-700 [Pubmed]
  9. Gipson CL, Tobias JD. Flail chest in a neonate resulting from nonaccidental trauma. Southern Medical Journal. 2006;99(5):536-538 [Pubmed]
  10. Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. American Journal of Diseases of Children. 1993;147(1):87-92 [Pubmed]
  11. Ng CS, Hall CM. Costochondral junction fractures and intra-abdominal trauma in non-accidental injury (child abuse). Pediatric Radiology. 1998;28(9):671-676 [Pubmed]
  12. Pandya NK, Baldwin K, Wolfgruber H, Christian CW, Drummond DS, Hosalkar HS. Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. Journal of Pediatric Orthopaedics. 2009;29(6):618-625 [Pubmed]
  13. Schweich P, Fleisher G. Rib fractures in children. Pediatric Emergency Care. 1985;1(4):187-189 [Pubmed]
  14. Smeets AJ, Robben SG, Meradji M. Sonographically detected costo-chondral dislocation in an abused child. A new sonographic sign to the radiological spectrum of child abuse. Pediatric Radiology. 1990;20(7):566-567 [Pubmed]
  15. Smith FW, Gilday DL, Ash JM, Green MD. Unsuspected costo-vertebral fractures demonstrated by bone scanning in the child abuse syndrome. Pediatric Radiology. 1980;10(2):103-106 [Pubmed]
  16. Strouse PJ, Owings CL. Fractures of the first rib in child abuse. Radiology. 1995;197(3):763-765 [Pubmed]
  17. Thomas PS. Rib fractures in infancy. Annales de Radiologie. 1977;20(1):115-122 [Pubmed]
  18. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. British Medical Journal (Clinical Research Edition). 1986;293(6539):100-102 [Pubmed]


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