Radiology : Thoracic Trauma Imaging
Skeletal Trauma
Infants and children with bruises to the thorax should be evaluated for skeletal thoracic trauma (ribs and spine) and intrathoracic trauma. Note that the lack of bruising does not necessarily mean that there is no injury to the chest. Careful physical examination to look for signs of point tenderness and crepitus is necessary. Compared to accidentally injured infants and toddlers, those who are abused (non-accidental injury) have fewer intrathoracic injuries and more rib fractures (Darling et al 2014). A fast MRI may be particularly useful for evaluation of spinal cord injuries.
Bony injuries to the thorax caused by child abuse may include injuries to the sternum, clavicle, shoulder, spine and ribs, and a careful history and physical will be necessary to help ascertain suspicion for abuse. Pneumothoraces may also be evident on chest X-rays. See the box below for information specific to rib fractures.
Spinal Injuries
Abusive spinal injuries can range from soft tissue injuries and edema to dislocations, fractures, and fractures with avulsions. Spinal injuries can occur anywhere along the spine, with biomechanical and developmental differences dictating differences in patterns of injury. While skeletal surveys with static images of the neck are the recommended initial tests for assessment of abuse in children less than or equal to age 2, whole spine MRI or fast MRI can offer valuable details to help visualize injuries. While consensus is still pending, whole spine MRI is recommended in cases of physical abuse. Local resources and concerns regarding sedation of the patient need careful consideration in the decision to obtain an MRI. In some centers, CT head imaging is obtained as part of a protocol for traumatic brain injury and includes the upper cervical spine to the level of C2 to image the craniocervical junction, an area at risk for injury in infants (Derinkuyu et al 2024).
Rib Fractures
Rib Fractures in Child Abuse
- Child abuse is the most common cause of rib fractures in infants <12 months old.
- A commonly recognized rib fracture resulting from child abuse is posterior rib fracture where the rib head articulates with the vertebral body. Rib fractures may also be observed in lateral locations.
- Rib fractures are often asymptomatic with no signs of external trauma, and therefore, may be missed if there is not an index of suspicion or other reason to obtain chest or rib films.
- Rib fractures generally are not displaced or fragmented, and therefore, may be undetected on static images until callus formation occurs at 7-10 days after injury.
- Oblique X-rays of the ribs, in addition to AP and lateral views, may assist in identifying rib fractures and are recommended as part of skeletal surveys.
(Paine et al 2019; Kriss et al 2020; Marine et al 2014.)
Intrathoracic Trauma
In children where there is a high suspicion of chest injury, or if static images are indeterminant for suspected rib fractures, a chest CT can be considered (Karmazyn et al 2022 and Otjen et al 2022).
