Posterior
rib fractures are highly indicative of non-accidental
trauma (
NAT) in infants. Since 2000, the "two-thumbs" technique for
cardiopulmonary resuscitation (
CPR) of newborns and infants has been recommended by the American Heart Association (AHA). This technique is similar to the grip on an infant's thorax while shaking. Is it possible that posterior
rib fractures in newborns and infants could be caused by the "two-thumbs" technique? Using computerized databases from three German children's hospitals, we identified all infants less than 12 months old who underwent professional
CPR within a 10-year period. We included all infants with anterior-posterior chest radiographs taken after
CPR. Exclusion criteria were
sternotomy,
osteopenia, various other
bone diseases and
NAT. The radiographs were independently reviewed by the Chief of Pediatric Radiology (MB) and a Senior Pediatrician, Head of the local Child Protection Team (IF). Eighty infants with 546 chest radiographs were identified, and 50 of those infants underwent
CPR immediately after birth. Data concerning the length of
CPR was available for 41 infants. The mean length of
CPR was 11min (range: 1-180min, median: 3min). On average, there were seven radiographs per infant. A total of 39 infants had a follow-up radiograph after at least 10 days. No
rib fracture was visible on any chest X-ray. The results of this study suggest
rib fracture after the use of the "two-thumbs"
CPR technique is uncommon. Thus, there should be careful consideration of abuse when these fractures are identified, regardless of whether
CPR was performed and what technique used. The discovery of
rib fractures in an infant who has undergone
CPR without underlying
bone disease or major
trauma warrants a full child protection investigation.