Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review.

BACKGROUND There is a diagnostic dilemma when a child presents with rib fractures after cardiopulmonary resuscitation (CPR) where child abuse is suspected as the cause of collapse. We have performed a systematic review to establish the evidence base for the following questions: (i) Does cardiopulmonary resuscitation cause rib fractures in children? (ii) If so, what are the frequency and characteristics of these fractures that may help to distinguish them from rib fractures caused by physical abuse? METHODS We performed a literature search of original articles, references, textbooks, and conference abstracts, published in any language from 1950 to 1 October 2005. Articles were identified from ASSIA, Caredata, Medline, Ovid Medline in Process, ChildData, CINAHL, Embase, ISI Proceedings, SIGLE, Science Citation Index, Social Science Citation Index, and TRIP databases. We included all studies that addressed rib fractures and CPR in children less than 18 years, and excluded review articles, expert opinion, consensus guidelines, and studies that were significantly methodologically flawed on critical appraisal. Each study underwent two independent reviews (with a third review if there was disagreement). Each reviewer used standardized criteria for study definition, data extraction, and critical appraisal, to determine the quality of the study and to establish if it met the inclusion criteria of this systematic review. FINDINGS Of the 427 studies reviewed, 6 were included: 1 case control, 4 cross-sectional, and 1 case series. These represent data on 923 children who underwent CPR. Three children sustained rib fractures as a result of resuscitation; all three of these had fractures that were anterior (two mid-clavicular and one costo-chondral). We did not find any child in the literature who had a posterior rib fracture due to CPR. Resuscitation was performed variably by both medical and non-medical personnel. CONCLUSION Rib fractures after cardiopulmonary resuscitation are rare. When they do occur, they are anterior and may be multiple. As the studies performed to date did not use the most sensitive techniques for detecting rib fractures, further prospective studies of children would be valuable to provide additional clarification on this question.