Ribs

ribsMy first full-blown trial in an actual courtroom was the result of a two-month-old baby boy, Mr. T, who suffered from a pair of broken ribs on each side of his tiny, little torso. Broken ribs in an infant are surprisingly difficult to detect, even with today’s x-ray and other bone-scanning technology. Essentially, the ribs are so small and soft that it is nearly impossible to see the telltale hairline cracks that you would otherwise find in fractures of the longer bones of the legs or arms. Or in the ribs of an adult, I guess.

It is not entirely unheard of for experienced physicians to struggle to find, or even miss detecting altogether, evidence of a broken rib in an infant. To make matters worse, the baby may not show any signs of distress. It is certainly intuitive to believe that if a baby has any kind of broken bone, then you will find that child screaming bloody murder from the moment the bone-breaking incident occurs. That’s not always how it works. I’ve had more cases than I care to admit involving children under age one who have shown up at an emergency room or pediatrician’s office because “something was just not right with them.” Parents come in because the kid has a fever, or is constipated, or isn’t feeding normally. Oftentimes, there is no evidence of bruising anywhere on the body and the child doesn’t seem to be in any discomfort.

Sometimes a parent will come in with a readily prepared story. The dog jumped on her. My five-year-old tipped over the crib. She rolled off the bed. I fell while I was carrying her down the stairs and I accidentally threw her against the dining table.

For one reason or another, in search of a proper diagnosis, maybe to rule out certain conditions, the doctors will often order images of the child. There’s a decent chance that the doctor has had some training in child abuse cases and knows what to look for, and if not, they know a physician well-versed in child abuse cases with whom they can consult.

Most of the time, it’s nothing. The majority of the time, a responsible parent brings the child in for treatment and there is no reason to suspect anything nefarious. X-rays and bone scans show normal, the child just has a cold or needs an adjustment in her feeding schedule, and everything works out well.

But sometimes, in a minority of cases that I wish were much smaller, an x-ray comes back that shows something a little peculiar. Something is just not right.

Broken ribs are hard to detect, but not impossible. The trouble in diagnosing them is that there usually isn’t evidence of the break itself. It’s rarely clear to a lay person like you or me that the rib is snapped in two, that the fracture is displaced. That is relatively rare and an extremely severe situation.

The ribs show up like wispy little twigs on the films. There might be something that catches the doctor’s eye. There might not. If you look closely, though, you may see a tiny little speck on the rib, a slightly enlarged spot or miniature nodule that looks just barely out of place. That’s calcification and that means that a bone is healing. A bone heals because it has been broken. An infant’s bone breaks because somebody made it break.

Babies’ ribs don’t crack on their own. Babies are spongy. Their bones, especially the ribs and skull, are relatively soft to allow for growth and expansion. Because they are soft, they can absorb an impressive amount of stress before they yield. Otherwise, people wouldn’t be able to handle babies because they would just break like Faberge eggs.

If you have ever held a baby then you know this. If you haven’t held a baby, maybe you’ve held a cat or a small dog. Those rib cages are soft, but protective; protective but bending; bending but not breaking.

Ideally.

It takes a lot of force to break a baby’s ribs. There are lots of ways to do it, lots of different angles in which you can hold the baby, but the fact of the matter is, you have to work to inflict that kind of injury.

Mr. T’s mom was a drug addict who loved vicious men. One of those men happened to be a drug dealer who fathered Mr. T. One night, about six weeks after he was born, dad beat on mom while he held the baby in the crook of his arm. Dad was pretty enraged, so as he got more and more agitated, his body, especially the arm he wasn’t using to beat mom, grew more and more rigid. The fight ended and mom stuck around.

About a week after that the same thing happened except this time dad held a gun to mom’s head. Again, he had Mr. T in his other arm and again he grew angrier and angrier during the course of the altercation. Eventually, by some miracle, mom convinced him to put down the gun and give her the baby. Again, she stuck around.

A few days later, mom and dad showed up at the emergency room with Mr. T in hand, upset that he was not his normal self. On staff that afternoon happened to be a renowned child-abuse expert in the region who sensed, the more mom spoke, that something was very wrong. He and the hospital social worker managed to separate mom and dad and at that point she couldn’t contain herself and she told them both all about the fights over the prior two weeks.

The doctor ordered films and discovered that Mr. T had two breaks on the left side of his body. He called Child Protective Services immediately. He then ordered follow up x-rays for about ten days after that guessing that he would find evidence of more breaks in the next set of films. He was right.

How did he know? Calcification is clearest and most discernible about a week to ten days after the traumatic incident. Mr. T’s mom told him enough that he knew there was a very high probability that the baby boy would start to show new spotting on his ribs after a few more days.

Mr. T had what we in the industry call multiple rib fractures in various stages of healing. The boy had endured two separate episodes of domestic violence that led to broken ribs. Mom didn’t do it, which would have probably been an excuse the first time.

But she went back and she allowed him to be in that position twice in as many weeks.

If the doctor hadn’t found the breaks and called CPS? I don’t think it is any exaggeration to say that Mr. T would have died well before his first birthday.

At the hands of his own parents.

That was over five years ago.

In the meantime I, and my colleagues, have had many other cases involving broken babies. Legs, arms, skulls, ribs, I’ve seen them all. A few weren’t the parents’ fault. A bunch were. A few were close enough that the judge had a genuinely difficult decision to make after all the evidence had been presented. Was the parents’ story plausible? Did the child have a medical condition that could explain the injury? Did somebody else have access to the child and hurt him?

Maybe.

These cases bother me. A lot. I find them worse than pretty much any other kind of case that I see, except maybe sex abuse and molestation. Substance-exposed newborns, certifiably crazy parents, meth or heroin addicts for parents, hoarding and dirty house parents. Those I can handle.

But these cases with physically broken newborns really, really get to me. Why? Because, by and large, you have to work really, really hard to break a baby.

How can someone do that?

Don’t worry, I won’t leave you with that thought. Instead, a happy story.

Mr. T was in the state’s legal custody for nearly two years, during which time he resided with his grandparents, who were steadfast in their protection of him. As required by law, we gave mom the opportunity to get away from dad, to get clean and put Mr. T first so she could have him back and have the state out of their lives. She couldn’t do it. She disappeared and stopped even visiting the child. Dad never bothered to try to get the child back and hid in the shadows like the coward he was the entire time Mr. T was a ward of the court. He never visited the child once.

I permanently terminated mom and dad’s parental rights eighteen months after he came to the hospital and Mr. T was adopted by his grandparents on the eve of his second birthday. They moved to a different state and after they did they sent me an email with a thank you and a picture of the curly-haired little boy playing in his sandbox, wearing red overalls and a brontosaurus sweatshirt, smiling in the sun, with the rest of his life ahead of him.

Guest post by RMK, attorney for a paycheck, not a living.

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5 thoughts on “Ribs

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