“Buckle” rib fracture: An artifact following cardio-pulmonary resuscitation detected on postmortem CT

Buckle rib fractures are incomplete fractures involving the inner cortex alone, and are rarely detected on routine chest X-ray or at autopsy. The characteristics of these fractures have not been well evaluated in situ although they are commonly observed on postmortem CT images especially following CPR. The postmortem CT findings in 42 cases showing buckle rib fractures caused by CPR were reviewed. The cause of death in all cases was non-traumatic. The shape, number, location, and distribution of these buckle rib fractures and their relationship to other types of rib fractures were evaluated using a novel oblique axial multiplanar reconstruction technique. Almost all incomplete rib fractures associated with CPR are buckle rib fractures (90.5%). All rib fractures were distributed from the second to ninth ribs with over 95% being within the second to seventh ribs. Buckle rib fractures are dominant in the seventh to ninth ribs and the proportion of buckle rib fractures located in the vicinity of the costochondral junctions increases with the lower ribs. Over 97% of all CPR associated rib fractures are located in the anterior one third of the ribs based on a new measurement method utilizing oblique axial multiplanar reconstruction of the CT data. When recognition of incomplete or buckle rib fractures on postmortem CT is taken into account, detection of symmetry and continuity of rib fractures typically associated with CPR is improved compared with the detection of complete fractures alone. Recognition of buckle rib fractures and their characteristics on postmortem CT is of benefit to the forensic pathologist in evaluating the possibility of CPR and the differentiation of resuscitative artifact from forensically significant visceral injury observed at autopsy.