Case 63

A 6-month-old baby presented to the emergency department as a ‘collapse’ at home. He was said to have stopped breathing and become blue. His father started mouth-to-mouth breathing and cardiac massage for under a minute. He responded rapidly. The parents called the ambulance and the baby was brought to the hospital. On assessment he was crying well and apyrexial and with normal oxygen saturations. He was assessed and investigations were performed to exclude sepsis including a chest radiograph which is shown below. This was an overexposed image which showed no evidence of pneumonia (Image 63). The baby was admitted and assessed and discharged home after 3 days. He was well and preliminary cultures were negative. https://s3-euw1-ap-pe-df-pch-content-public-u.s3.eu-west-1.amazonaws.com/9780429170423/236ca68c-f283-4df8-88b2-3b8ff49bccc9/content/fig63.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/>

Five days after admission, the radiologist contacted you saying she was concerned. What do you see on the radiograph? What does this mean?

Could these signs all be related to the inexpert cardiopulmonary resuscitation (CPR) that the father performed in his panic?

What would you do?

The radiologist had identified a row of healing rib fractures laterally in the right third to fifth ribs and posteriorly in the right fifth rib. Do not be surprised if you did not see these on an x-ray taken for other purposes. Initial clinical and non-specialist radiology reviews often miss old rib fractures on an image performed for other reasons (e.g. to exclude pneumonia).

Finding unexplained healing posterior or lateral rib fractures always raises the issue of non-accidental injury. ¹ These all show healing reactions. In a 6-month-old these are over 10 days old and likely to be weeks old (e.g. 2–4 weeks). They do not relate to the acute event when the baby collapsed. Squeezing around the chest can cause lateral and posterior rib fractures. This may be associated with shaking injury. Baby ribs tend to bend with cardiac massage rather than fracture. The rib fracture rate even with prolonged cardiac massage is under 2% and these kinds of fractures are usually anterior.

The baby should be recalled quickly, for clinical assessment and evaluation. Delay in reassessment may mean the baby is exposed to further trauma.