Gregory Wallace, DO

A 6-month-old girl was brought to the emergency department (ED) of a rural hospital by her mother and father with fever, cough, and irritability. Both parents appeared to be developmentally delayed but acted appropriately under the circumstances.

The child was born prematurely at 34 weeks; she had a long complicated stay in the newborn intensive care unit (NICU). She had required ventilation for several weeks and the parents were certain she had been given “fluid pills” (furosemide) because of lung “problems.” When later questioned, the parents also stated that the child had received CPR on 2 occasions during her stay in the NICU.

The infant’s immunizations were up to date.

The physical examination showed the child to be small for her age. Her heart rate was 155 beats/min; respiratory rate, 48 breaths/min; temperature, 101.3°F. The child appeared well-hydrated, clean, and free of signs of trauma. She was extremely irritable, however. There was concern about lung “congestion” noted on the ED report. The 

 were as shown. The ED physician made a diagnosis of pneumonia. Rib fractures were also noted, of which the parents were unaware.

The ED physician recommended admission overnight.



By the following morning, records obtained from the NICU showed there was no history of any fractures at time of discharge 3 months earlier.

The father was very anxious; his anxiety had escalated to the point that he was asked by security to leave the hospital. He was concerned that he was being accused of child abuse. He was under suspicion at this point, but no one had yet approached him or his wife. 

The child had a head CT scan as well as retinal examination. Results of both were normal.

Child Protective Services was consulted; the mother told the social worker how the father had squeezed the baby’s chest when the baby cried. The father confessed to the police later in the day. The mother lost custody of the child for 6 months while she completed parenting classes and the father served prison time for child abuse.




Without question, this is the most straightforward case of child abuse involving rib fracture with which I have ever been involved. There was eyewitness testimony and a perpetrator confession within less than 12 hours of the clinical presentation.

Rib fractures suggest abuse and are a lone finding in 29% of skeletal injury cases.



Without the father’s confession and the x-ray films from the NICU, this case would have been very difficult to prove. It is commonly accepted that prematurity as well as administration of total parenteral nutrition or furosemide all predispose to fractures.

 The fact that this child had also received CPR would have been a point of contention as well.

 In similar cases, there are claims that rib fractures are the result of birth fractures becuase of the baby’s size or method of delivery.


1. Barsness KA, Cha E-S, Bensard DD, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. 

. 2003;54:1107-1110.
2. Amir J, Katz K, Grunebaum M, et al. Fractures in premature infants. 

 1988;8:41-44. http://www.ncbi.nlm.nih.gov/pubmed/3121670.
 3. Dolinak D. Rib fractures in infants due to cardiopulmonary resuscitation efforts. 

2007;28:107-110.
4. Hartmann, RW Jr. Radiological case of the month. 

. 1997;151:947-948.
5. Bulloch B, Schubert CJ, Brophy PD. Cause and clinical characteristics of rib fractures in infants. 

. 2000;105:e4-8. http://www.pediatricsdigest.mobi/content/105/4/e48.full.


 

Articles

Rib fractures suggest abuse and are a lone finding in 29% of skeletal injury cases.

Rib Fractures: A Case of Abuse in a 6-Month-Old

A 6-month-old girl was brought to the emergency department (ED) of a rural hospital by her mother and father with fever, cough, and irritability. Both parents appeared to be developmentally delayed but acted appropriately under the circumstances.

The child was born prematurely at 34 weeks; she had a long complicated stay in the newborn intensive care unit (NICU). She had required ventilation for several weeks and the parents were certain she had been given “fluid pills” (furosemide) because of lung “problems.” When later questioned, the parents also stated that the child had received CPR on 2 occasions during her stay in the NICU.

The infant’s immunizations were up to date.

The physical examination showed the child to be small for her age. Her heart rate was 155 beats/min; respiratory rate, 48 breaths/min; temperature, 101.3°F. The child appeared well-hydrated, clean, and free of signs of trauma. She was extremely irritable, however. There was concern about lung “congestion” noted on the ED report. 

The chest film 

 findings were as shown. The ED physician made a diagnosis of pneumonia. Rib fractures were also noted, of which the parents were unaware.

The ED physician recommended admission overnight.

How strongly do you suspect abuse? What physical cause might mimic these clinical findings?

We invite you to leave your comments below; then 

Rib fractures suggest abuse and are a lone finding in 29% of pediatric skeletal injury cases.

Rib Fractures in a 6-Month-Old With Pneumonia: Abuse-or Mimic?

A 4-year-old girl presented to her primary care physician with these lesions that had been present for several weeks. The child’s mother was increasingly concerned that the lesions were not of an innocent nature. The first lesion had started on the anterior aspect of the child’s leg; new lesions were now spreading to the other leg and toward the groin. The mother was worried that these were sexually transmitted or abuse-related.

The mother had 2 other children and neither had any rash. The only variable between this child and her siblings was that she attended daycare.

The physician was certain of the cause of the rash, but uncertain of its relationship to child abuse.

Please click here for the answer and discussion.

This child's mother was worried that these lesions were sexually transmitted. What's your suspicion?

Progressive Rash on Child’s Leg and Groin: Child Abuse-Or Mimic?

Telephone consultation with local child abuse center provided the following reassuring information. This was a case of molluscum contagiosum, unrelated to abuse.

There were no allegations of abuse in this case. The interview provided no reason to suspect abuse and the social worker found no risk factors in the family for abuse.

After the social concerns were ruled out, the issue became a medical one. The diagnosis was molluscum contagiosum. The highest incidence of this very common viral skin infection occurs in children under 5 years old; however, the disorder is increasingly seen in sexually active teens and in immunodeficient individuals.

Molluscum spreads through direct contact from playing, sports contact, fomites, sexual activity, and breast feeding.

 The incubation period is 2 to 7 weeks, but may be as long as 6 months. Common locations for the lesions are legs, abdomen, genitals, and eyes. Coitus is not a necessary precursor to genital infection, which can occur by self-inoculation if the lesions are present elsewhere on the body. If lesions are present only on the genitals, however, it is prudent to rule out abuse.

Molluscum is self-limited; lesions generally resolve within 6 to 12 months. Nevertheless, multiple treatment regimens are available.

 Spread of the infection can be limited by covering lesions with clothing or a light bandage. Molluscum does not exclude the child from school or public swimming pools.

In this patient’s case, once the family was reassured that the lesions were not the result of abuse, no treatment was sought. After checking at the daycare and with neighborhood friends, the family found other children with the same lesions.

As with many conditions, abuse needs to be considered in the differential diagnosis of molluscum just to be complete. A through history will eliminate many possible considerations.




1. Feigen RD, Cherry JD, Demmier GJ, Kaplan SL. 

Textbook of Pediatric Infectious Diseases.

 5th ed. Philadelphia: Saunders; 2003:587;3347-3348.
2. American Academy of Pediatrics. Molluscum contagiosum. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. 

Red Book: 2009 Report of the Committee on Infectious Diseases. 

28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:466.
3. Silverberg NB. A practical approach to molluscum contagiosum. 

The mother of this 4-year-old girl was concerned that these lesions were sexually transmitted. The physician recognized them as molluscum, but was uncertain of the potential relationship of this rash to child abuse.

Gregory Wallace, DO

Articles

Rib Fractures: A Case of Abuse in a 6-Month-Old

Rib Fractures in a 6-Month-Old With Pneumonia: Abuse-or Mimic?

Progressive Rash on Child’s Leg and Groin: Child Abuse-Or Mimic?

Molluscum Contagiosum in a 4-Year-Old Girl