Pediatric Chest: A Review of the Must-know Diagnoses

Shreya Sood, MD; Julia Rissmiller, MD; Anastasia Hryhorczuk, MD


Appl Radiol. 2018;47(4):4-14. 

In This Article

Non-accidental Trauma

In children under 2 years of age, fractures are highly associated with physical abuse.[28,29] Some of these non-accidental injuries manifest in the bony thorax and may be incidentally discovered on chest radiographs. For instance, posterior rib fractures occurring at the head/neck of the rib near the costovertebral articulation, represent one of the most specific fractures encountered in non-accidental trauma (NAT) (Figure 11A).[29–31] These occur due to anteroposterior compression of the chest wall, which levers the rib over the transverse process.[30,32] This contrasts with lateral rib fractures, which are more common in non-abusive, accidental injuries.[33,34] Oblique views of the ribs are crucial for detecting posterior rib fractures.

Figure 11.

11-month-old infant male with multiple bruises and conjunctival hemorrhages. (A) AP chest radiograph demonstrates multiple worrisome rib fractures including: fracture of posterior left 9th rib (thick arrow), subtle fracture of the posterior right 9th rib (thin arrow), fractures of anterior left 6th and 7th ribs (hollow circle) and fractures of the anterior right 5th and 6th ribs (hollow square). (B) Coned-down radiograph of the left shoulder demonstrates a fracture through the left acromion (thick arrow) and left proximal humeral metaphysis (thin arrow). The right proximal humeral metaphysis was also fractured, but not included in this image. Findings are compatible with non-accidental trauma (NAT).

Other, less common, but highly specific chest wall fractures in NAT include acromial fractures, with a prevalence of roughly 5% among abused children (Figure 11B).[28,35,36] Additional concerning injuries include non-acromial scapular fractures and non-birth related clavicular fractures. Recognizing these fractures on chest radiography is crucial, as these are often clinically occult, and identifying these lesions may permit appropriate management of a vulnerable child.