UMEM Educational Pearls

Title: What's the diagnosis? Case by Dr. Jennifer Guyther

Posted: 11/25/2012 by Haney Mallemat, MD (Emailed: 11/26/2012) (Updated: 11/26/2012)
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Question

2 year-old male with past medical history of asthma presents with fever and respiratory distress. CXR is shown below. What’s the diagnosis? (Hint: ...look beyond the obvious)

Answer

Answer #1: Multifocal opacities predominantly in left lower lobe representing pneumonia

Answer #2 Healing left-sided rib fractures involving the lateral aspects of ribs 8 through 10^thsuspicious for non-accidental trauma (see X-ray below)

Pediatric CXR pearls

Always remember to thoroughly examine x-rays to screen for abnormal findings.
Posterior rib fractures are highly suspicious for abuse in pediatric patients as the differential is very small beyond accidental trauma.
General risk factors increasing the risk for pediatric rib fractures:
- Gestational age less than 30 weeks
- Low-birth weight
- Chronic lung disease
- Chronic diuretic use
- Prolonged parenteral nutrition

Bottom line: Screen patients for the above risk factors when rib fractures have been identified, but always think of abuse and the child’s safety first….and don’t forget to thoroughly examine radiology despite finding one abnormal finding.

Reference: Cosway et al. Diagnostic indicators for NAI in children with rib fractures: A retrospective study. Arch Dis Child 2011; 96 (supplement)

References

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