Rib fractures

NSHPT in most cases presents within the first six months of life. Affected infants have severe, symptomatic, PTH-dependent hypercalcemia, along with the bony changes of severe hyperparathyroidism. Infants with NSHPT can exhibit polyuria, dehydration, hypotonia, and failure to thrive (Brown et al, 1997 Eftekhari and Yousefzadeh, 1982 Grantmyre, 1973 Heath, 1989a Marx etal, 1985). A prominent feature of the disease is the associated hyperparathyroid bone disease, which can be associated with multiple fractures. Rib fractures can in some cases produce a... 

A 41-year-old woman, with liver lacerations, rib fractures, and pneumothorax after a motor vehicle accident, was given haloperidol for agitation on day 7. During the first 24 hours she received a cumulative intravenous dose of 15 mg, 70 mg on day 2, 190 mg on day 3,160 mg on days 4 and 5, and 320 mg on day 6. An hour after the first dose of 80 mg on day 7, she had ventricular extra beats followed by 5-beat and 22-beat runs of ventricular tachycardia. The rhythm strips were consistent with polymorphous ventricular tachycardia or torsade de pointes and the QTC interval was 610 ms (normally under 450 in women). She received intravenous magnesium sulfate 2 g. Concurrent medications included enoxaparin, famotidine, magnesium hydroxide, ampicillin/sulbactam, nystatin suspension, midazolam, and 0.45% saline with 20 mmol/1 of potassium chloride. She had no further dysrhythmias after haloperidol was withdrawn. Eight days after the episode of torsade de pointes she had a QTC interval of 426 ms. 

Although intrapleural streptokinase does not cause systemic fibrinolytic effects, there can be local fibrinolytic effects. In a case series describing the use of intrapleural streptokinase or urokinase in 26 patients, one developed major oozing from rib fractures sustained 1 month before therapy (89). This local bleeding required two thoracotomies. It is not clear from the report if streptokinase or urokinase was used in this patient, but streptokinase was used in most of patients in this series. Furthermore, the dose used was also not clear, with streptokinase doses of 100 000-750 000 lU. 

Compression Rib fracture Stable ribcage Flail chest... 

Fig. 6.3. Blown up chest radiograph and corresponding bone scan showing posterior left rib fractures. Their detection is improved by the use of the bone scan...

Rib fractures comprise 5%-27% (Akbarnia et al. 1974 Barrett and Kozlowski 1979 Herndon 1983) of all fractures in abused children and are probably even more common than published figures suggest because of the difficulty in demonstrating them radiologically in the acute situation prior to the appearance of callus. Any part of the rib may be affected, and fractures are frequently bilateral and multiple, although 20% of rib fractures are solitary (Carty and Pierce 2002) (Fig. 11.6). Rib fractures in infancy are unusual because normal ribs are so pliable. Considerable force is required to produce them and even in children who undergo cardiopulmonary resuscitation, 99.5% do not develop rib fractures (Feldman and Brewer 1984 John et al. 2005). Posterior rib fractures do not occur as a result of cardiopulmonary resuscitation. Thomas (1977), in a review of over 10,000 chest X-rays of infants... 

In contrast to diaphyseal appendicular fractures the majority (over 81%) of rib fractures are occult (Merten et al. 1983). They most commonly result from a compressive, squeezing force applied to the... 

Many posterior rib fractures only become visible with the appearance of callus. In a post-mortem and radiological study, Kleinman et al. (1988) failed to identify any acute posterior rib fractures and more than 50% of healing posterior rib fractures by conventional radiography. Evidence of healing, as manifested by callus formation, was essential for reliable diagnosis of fractures near the costo-vertebral articulations. Thus failure to observe the fracture at presentation and the appearance of callus after admission to hospital is not necessarily evidence of injury after admission (Fig. 11.7). 

Fig. 11.7a,b. Multiple rib fractures that could be interpreted as appearing after admission to hospital, a On the admission chest radiograph the only rib fractures to be convincingly demonstrated are those involving right 6 and ribs (arrowheads). Note also the pleural shadow immediately deep to the fractures, presumably the result of extrapleural hae-matoma. b The follow-up radiograph obtained 20 days later shows callus on the 3 to 8 ribs (arrowheads). The callus has a similar appearance on each rib and the healing rib fractures lay in a line, one above the other. The fractures were, no doubt, sustained at the same time prior to admission... 

Barsness KA, Cha ES, Bensard DD et al (2003) The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma 54 1107-1110 Beals RK, Tufts E (1983) Fractured femur in infancy the role of child abuse. J Pediatr Orthop 3 583-586 Brill PW, Winchester P, Kleinman PK (1998) Differential diagnosis 1. Diseases simulating abuse In Kleinman PK (ed) Diagnostic imaging of child abuse, 2nd edn. Mosby, St Louis, pp 178-196... 

Feldman KW, Brewer DF (1984) Child abuse, cardiopulmonary resuscitation and rib fractures. Pediatrics 73 339-342 Galleno H, Oppenheim WL (1982) The battered child syndrome revisited. Clin Orthop 162 11-19 Graif M, Stahl-Kent V, Ben-Ami T et al (1988) Sonographic detection of occult bone fractures. Pediatr Radiol 18 383-385 Haase GM, Ortz VN, Stakianakis GN et al (1980) The value of radionuclide bone scanning in the early recognition of deliberate child abuse. J Trauma 20 873-875 Herndon WA (1983) Child abuse in a military population. J Pediatr Orthop 3 73-76... 

John N, Maguire S, Mann M K et al (2005) Does cardiopulmonary resuscitation cause rib fractures in children A systematic review. Arch Dis Child 90 [Suppl 11] A41-A43 Johnson K, Chapman S, Hall CM (2004) Skeletal injuries associated with sexual abuse. Pediatr Radiol 34 620-623 Kemp AM, Butler A, Morris S et al (2006) Which radiological investigations should be performed to identify fractures in suspected child abuse Clin Radiol 61 723-736 Kempe CH, Silverman FN, Steele BF et al (1962) The battered child syndrome. JAMA 181 17-24 King J, Diefendorf D, Apthorp J et al (1988) Analysis of 429 fractures in 189 battered children. J Pediatr Orthop 8 585-589... 

Fractures of the scapula are rare and are typically the result of high energy trauma. Immediate concern is therefore with regard to associated rib fractures, pulmonary or cardiac contusion and mediastinal injury. The presence of tenderness and swelling around the shoulder indicates the possibility of a scapular fracture, which can be evaluated by CT. Indirect trauma leads to avulsion injuries (Goss 1996). 

Govindarajan R, Bakalova T, Michael R, Abadir A. Epidural buprenorphine in management of pain in multiple rib fractures. Acta Anaesthesiol Scand 2002 46(6) 660-665. 

Some of the techniques may be limited or inappropriate, depending on the patient s medical condition. Splenomegaly, hepatitis, pneumothorax, rib fracture, osteoporosis, pyelonephritis, thrombotic phenomenon, and recent surgery may preclude the use of thoracic manipulation for fear of further complications. Anemia, pregnancy, and a history of neoplastic processes are relative contraindications. 

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