The rib cage

Caffey made no mention of rib fractures when he described the association between subdural hematomas (SDHs) and long bone fractures in abused children in 1946 (1). In fact, it was not until the early 1950s that the importance of rib fractures in the radiologic spectrum of child abuse was appreciated (Fig. 5.1) (2–5). In an interesting recent report, Wheeler et al. described rib fractures and other osseous injuries in the skeletal remains of a 2–3-year-old child from Kellis 2, a Romano-Christian period cemetery in the Dakhleh Oasis, Egypt. The authors suggested that the unusual pattern of skeletal trauma and healing events were due to multiple abusive episodes (6).

The presence of rib fractures is now often central to the radiologic diagnosis of child abuse. A review of the older literature found that rib fractures constituted from 5 to 29% of all fractures detected in children surviving assaults upon them (5, 7–13). More recent data indicate that rib fractures are likely the most common skeletal injuries noted in abused children. In a database review of patients drawn from multiple centers, including postmortem material, Boal et al. found fractures in 213 of 303 (70%) child abuse cases (14). Of a total of 2025 fractures, 1608 (79%) involved the rib cage. In a postmortem study, Kleinman and colleagues found that 51% of all fractures in 31 abused infants who died involved the rib cage (15).