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Rib fractures in children--resuscitation or child abuse?
1Department of Legal Medicine, University of Munich, Germany.
Insights
Rib fractures in children during resuscitation are rare, especially in dorsal areas. Dorsal rib fractures in infants without bone disease strongly suggest physical child abuse, not resuscitation errors.
Area of Science:
- Forensic Pathology
- Pediatric Traumatology
Background:
- Resuscitation efforts, including closed-chest massage, can lead to thoracic injuries.
- Distinguishing between resuscitation-induced fractures and those from physical abuse is critical in pediatric autopsies.
Purpose of the Study:
- To analyze autopsy findings of rib fractures in children.
- To differentiate between fractures caused by resuscitation and those indicative of child abuse.
Main Methods:
- Retrospective review of autopsy reports from 233 children (5 days to 7 years).
- Categorization of deaths into non-traumatic (190 cases) and traumatic (43 cases).
- Analysis of resuscitation attempts and fracture locations.
Main Results:
- Only 2 of 190 non-traumatic deaths with resuscitation showed bilateral midclavicular rib fractures.
- 15 of 43 traumatic deaths had fractures, primarily of the posterior ribs.
- Physicians caused resuscitation injuries more frequently than non-medical persons.
Conclusions:
- Ventral thoracic fractures can occur during resuscitation.
- Dorsal rib fractures in infants without metabolic bone disease are strong indicators of physical child abuse.
- Findings refute claims of inexpert resuscitation causing rib fractures.
Abstract:
The autopsy reports of 233 babies and children aged between 5 days and 7 years, including 190 cases of non-traumatic and 43 cases of traumatic death, were reviewed. In 94 out of 190 cases of death due to natural causes, attempted resuscitation (closed-chest massage) was performed and only in 2 cases could fractures of the ribs localized on both sides in the midclavicular line be observed. In 15 of the 43 cases of death due to traumatic events, fractures mainly of the posterior ends of the ribs occurred. These observations support the published findings of other authors which indicate that fractures of ventral parts of the thorax can occur during resuscitation. Fractures localized in particular in dorsal parts of the chest wall of infants without metabolic bone diseases, however, must be interpreted as a strong indication of physical child abuse. It was observed that relevant injuries due to resuscitation are caused much more frequently or almost exclusively by physicians than by non-medical persons. This finding refutes any possible claims that rib fractures were caused by inexpert resuscitation in a panic-like reaction.