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