Keywords:
Paediatric, Musculoskeletal bone, Forensic / Necropsy studies, CT, Medico-legal issues, Forensics, Pathology, Trauma
Authors:
A. Paterson, P. Ingram, C. Thornton; Belfast/UK
DOI:
10.1594/ecr2011/C-1587
Results
There were 16 male and 10 female children.
Age range was 1 day - 4 years.
None of the children included in the study population had any clinical or radiographic evidence of a bone dysplasia or metabolic abnormality. No other fractures were seen on the skeletal surveys. Five children (19%) were found to have rib fractures on the CT images, that could not be seen on chest radiographs.
The number of fractures detected by CT varied from 5 - 20.
Individual case histories where rib fractures were detected on the CT examinations:
- Index case.
14-week-old male infant transferred to the paediatric intensive care unit (PICU) from a local district general hospital (DGH).
On admission he was cold and unresponsive, and had visible bruising over his trunk and extremities.
An initial CT brain in the DGH showed sub-dural and sub-arachnoid haemorrhage,
contusions and evidence of hypoxia.
Repeat imaging on transfer included CT of the chest,
abdomen and pelvis to assess for suspected internal injuries (none identified).
He died from his brain injuries less than 48 hours after his admission to hospital,
when a skeletal survey was performed (Figures 1-6).
Final cause of death: NAI
- 5-month-old male infant found lifeless in the parental bed one morning.
He had been sleeping with both his parents and was found lying beneath his father's legs.
He underwent prolonged and extensive resuscitation (Figures 7-9).
Final cause of death: unascertained SUDI.
Rib fractures attributed to CPR
- Male infant found dead in his cot one morning.
He underwent prolonged and extensive resuscitation.
No further history available (Figures 10-11).
Autopsy result awaited.
Rib fractures presumed due to CPR
- 4-year-old girl.
Complex medical history including a recent diagnosis of autism.
Fell down a flight of stairs 5 days prior to admission.
Well initially,
though had a bruise on her right temple.
Became withdrawn,
refused to eat and developed diarrhoea.
Presented moribund to her local DGH,
where she was resuscitated.
Initial imaging showed a sub-dural haematoma,
left-sided rib fractures and a left lower lobe pneumonia.
Her serum sodium was recorded at 177mmol/l.
She had previously been on the "at risk" register for bilateral leg fractures,
with her father listed as the perpetrator,
though he was abroad at the time of the current events.
Despite maximal therapy after transfer to the PICU,
she died 5 days after admission (Figures 12-13).
Despite her age,
this patient was managed as a potential NAI victim,
given her past medical history and several unexplained aspects of her final illness.
The case remains under police investigation.
Rib fractures in keeping with the documented fall prior to admission
- 15-month-old female infant transferred to the PICU from her local DGH.
She was unconscious at the time of transfer,
with fixed and dilated pupils.
Physical examination revealed multiple bruises over her body.
CT brain showed bilateral sub-dural haematomas and evidence of hypoxic-ischaemic injury.
Body CT demonstrated abnormalities consistent with the hypoperfusion complex,
along with extensive soft tissue swelling and oedema around the vagina and rectum.
She underwent extensive but ultimately unsuccessful resuscitation (Figures 14-17).
Final cause of death: NAI
Patient No. |
CXR findings |
CT results |
Autopsy results |
% agreement between CT and pathology |
1 |
Acute #s of Lt R9 and Rt R10 at CVJ
Suspected acute # Lt R10 at CVJ
Suspected acute #s Lt R9 & Rt R7 at CCJ
|
Acute # Lt R9 at CVJ
Suspected acute #s Lt R8,
Rt R9 & and R10 at CVJ
Suspected acute #s B R5,
R7,
R8,
R9,
R12 at CCJ
|
Confirmed acute #s Lt R8,
R9 & R10,
Rt R9 & R10 at CVJ
Further acute #s B R5,
R6,
R7,
R8 and Lt R9 at CCJ
|
Pathology confirmed 11/14 (79%) of rib #s and found 3 additional ones |
2 |
No #s seen |
Acute #s B at R5 & R6 CCJ
Acute buckle #s Rt R2,
B R3 & R4 lat to CCJ (internal cortices only)
|
Acute anterior #s B R3,
R4,
R5 & R6 |
Pathology confirmed 8/9 (89%) of rib #s |
3 |
No #s seen |
Acute buckle #s B R4 & R5,
Lt R6 lat to CCJ (internal cortices only) |
Awaited |
|
4 |
Healing lateral #s Lt R6-10 inclusive at rib angles |
Healing lateral #s Lt R6-10 inclusive at rib angles
Buckle #s Rt R2 & R5 lat to CCJ (outer cortices only)
|
Healing #s at angles of Lt R6-10 inclusive
Buckle #s outer cortices of Rt R2 & R5
|
Pathology confirmed 7/7 (100%) of rib #s |
5 |
Healing #s left 7th & 8th ribs,
right 3rd-6th ribs inclusive laterally and right 9th rib at CVJ |
Healing #s Lt R1 in MCL,
Lt R7 & R8 laterally,
Rt R2 antero-lateral,
Rt R3,
R4 & R6 laterally,
Rt R9 at CVJ
Acute #s Lt R4-9 inclusive,
Rt R6 & R7 at CCJ
Acute #s Lt R4-6 inclusive and Rt R7 in MCL
|
|
Not possible.
Autopsy performed prior to radiology result available, with the body being released immediately for burial.
Not all ribs identified as fractured at CT were examined by the forensic pathologist |
Table showing results of chest radiographs,
CT chest studies and autopsy
Key to table symbols: # - fracture,
B - bilateral,
CCJ - costo-chondral junction,
CVJ - costo-vertebral junction,
Lt - left,
MCL - mid-clavicular line, Rt - right,
R + number - corresponding rib number
Summary of CT results:
The types of fracture seen on the CT studies varied,
depending upon their underlying cause,
as determined by autopsy.
- In cases with a final diagnosis of NAI,
both acute and healing fractures were seen,
fractures occured in all ribs and at all sites along the rib arch.
Posterior rib fractures were not seen in any other circumstances
- In those infants in whom NAI was excluded as a cause of death,
and who had undergone extensive resuscitation by paramedical staff at the scene and/or upon arrival at the Emergency Department,
fractures were located anteriorly,
the majority of which were lateral to the costo-chondral junctions,
were bilateral and symmetric,
between ribs 3 - 6 inclusive and more typically appeared as buckle fractures on the internal cortices of the ribs
- Traumatic (appropriate history given) fractures were seen at the site of impact and were associated with overlying soft tissue swelling. Buckle fractures on the outer cortices of the ribs opposite to the site of impact were also identified