Case history

Case history #1

An 86-year-old lady is admitted following a fall at home. She is complaining of chest pain and shortness of breath. On examination, there is shallow respiratory effort, raised respiratory rate, and tenderness on palpation of the chest wall. Percussion of the lower left chest is dull, suggestive of haemothorax.

Case history #2

A 3-year-old boy presents to the family doctor for irritability and chest pain. The mother denies any known injury and does not know what precipitated the complaints. Physical examination shows a well-nourished child in no significant distress. He has two small bruises on his buttocks and a small bruise over his left mid-chest wall, which are tender to palpation. Apart from the tenderness, he has a normal examination.

Other presentations

Because of pliability and increased elastance of cartilage and less ossified ribs, the paediatric ribcage can absorb a substantial amount of kinetic energy without fracturing. Despite the lack of bony trauma, the child may suffer soft tissue or intrathoracic injury, or both. Therefore, when rib fractures are identified in the paediatric patient, it is indicative of extreme force.[1]​ In young children, studies have shown rib fractures are a result of child abuse 65% to 100% of the time.[2][3][4][5][6][7]​ The probability of abuse in children with intracranial injury and retinal haemorrhage alone is about 33%, but this probability increases to about 98% with the addition of rib fractures.[8][9]​ Although much less common, rib fractures can also occur after serious accidental injuries, birth trauma, or secondary to bone fragility.[10]​ Fractures in young children may be asymptomatic. In a case series of 26 infants (aged <1 year) with rib fractures under observation for or with an abuse diagnosis, no infants showed signs of pain at physical examination and rib fractures were rarely associated with physical findings such as bruises, swelling, or gripping marks.[11]​ In one case, a popping sound with local crepitation was identified on examination.[11]​ Posterior rib fractures are more commonly found in abuse.[7][12]

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