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little_detailsMy question is mostly regarding how realistic it would be to identify old rib fractures on x-ray. Research has yielded some promising results, but I couldn't quite get answers that fully address this specific scenario.
Putting my question and the context under a cut because it involves discussion of child physical abuse. (It's also a little on the long side.)
This character is around twenty years old in the late 80s (in NYC). There's a history of parental abuse, including physical abuse, but he sees it as not having been "that bad" because 1) he's downplayed the injuries that infrequently occurred or genuinely not realized the extent of them and 2) he thinks it could have been worse. These are obviously problematic and potentially hurtful ideas, but that's one of the things that I want to address. In the story, he's in college, and he's started seeing a therapist for the first time, but he's very reticent to actually describe any of the things troubling him (namely depression, anxiety, and what we would now probably diagnose as C-PTSD) at least partially because he's concerned that they'll reflect poorly on his mother, of whom he feels very protective (for valid but dysfunctional reasons).
Here's the plan:
In the course of the story, he's injured in an accident doing something noble. He gets talked into going to the ER and gets a chest x-ray (because he hit the curb and landed hard on his ribs), and while the doctor is showing him the film to reassure him that his ribs are not broken (while still encouraging him to rest because they're pretty badly bruised), he mentions a couple of healed breaks. The character was unaware that he'd ever had a rib fracture in that area, though he'd suspected, after a relatively recent event, that he might have broken a rib on the other side; he didn't seek treatment for it, so he never got an x-ray to be sure. The recent incident was within the previous two years and occurred following puberty, so I'm assuming that it's still clearly visible on the x-ray. But my question concerns the other healed posterior fracture, in one of the 9th or 10th ribs, that would have occurred maybe eight years prior, around the age of twelve, from being slammed into a wall or to the ground with considerable but not extreme force.
From the research I was able to do, I've gathered that it's not uncommon to have a simple rib fracture and not realize, particularly in the lower ribs, and that these are occasionally found years after the fact on x-ray while looking for something else, with patients sometimes reporting no memory of how it could have occurred. So it seems like a case could be made for that sort of reveal. But because of the greater remodeling potential in childhood, I'm wondering how realistic this is? I've seen some sources claiming that a healed childhood fracture will virtually be undetectable and others claiming that it can be seen, especially depending on how it heals and whether there are any complicating factors. I figure since the fracture was missed and there were a lot of pressures on this kid, he didn't rest, so that may have aggravated and thus lengthened or complicated the healing of the initial rib injury. This is a character with a fairly high pain tolerance and some level of disconnect from his body even at that age, so I think there’s some leeway in terms of whether he might realistically not clock how bad it is, as long as he’s still functional.
Basically, I'm trying to find the line between a childhood injury severe enough to be detectable almost a decade later in adulthood (by a highly skilled and particularly observant radiologist who's really looking at the ribs specifically, so more likely to catch it) and one not so severe that it would have been too unrealistic for it to go unnoticed or that would have caused complications and further injury if left untreated. I'm also wondering if fractures that healed in childhood look in any way visibly distinct from fractures that healed in adulthood or if the older healed injury would look much different from the more recent fracture (eight years versus two years out from the initial injuries), simply because it's had more time to heal, and thus be distinguishable (because while I gather that it's difficult to date injuries via radiography, I wonder if relative age could be determined--like, maybe they can't say when it happened, but they can say that this one's older than that one at least). And if so, how a doctor might describe this to a patient.
The conclusion I want him to come to is that, realistically, the only explanation for the older/other fracture is the abuse (either because it’s clearly older than the fracture caused by the more recent event or because it’s in a different area that he doesn’t specifically recall injuring). He remembers one incident in particular, after which he had trouble bending down to tie his shoes or picking up his younger sibling without significant pain for some time, and assumes that that was likely the event. Because his mother was recovering from pneumonia that winter and was already overworked and overburdened to begin with, she missed it, and he didn’t say anything because he didn’t want to worry her and he was already used to hiding discomfort/his problems by then (which is another realization he’s going to contend with).
The idea is that it's shocking to him that the physical abuse was more severe than he'd realized--that it actually was "that bad", even though he wasn't being beaten and, in his mind, that’s how he conceptualizes abuse--but that the realization doesn't actually change his feelings about what occurred or his relationship with the abusive parent. If he'd never learned about the injury, the damage would still have been done, you know? The severity isn't what made it wrong and hurtful. This sort of forces him to reframe his experiences and reflect on how he'd minimized what happened, and it brings him closer to understanding the many forms abuse can take--that it's not all about the physical damage. The end result of this is that he brings it up in therapy, with the intention of finally being honest about some of the things that have been troubling him, though he's now very concerned that the therapist will judge his mother for not having noticed her kid walking around with broken ribs.
Anyway, I realize that some of this is being exaggerated for dramatic effect, but is this a scenario that’s completely unworkable? I'm not married to the particulars of it, but the underlying idea is sort of pivotal for character development at that juncture of the story.
Putting my question and the context under a cut because it involves discussion of child physical abuse. (It's also a little on the long side.)
This character is around twenty years old in the late 80s (in NYC). There's a history of parental abuse, including physical abuse, but he sees it as not having been "that bad" because 1) he's downplayed the injuries that infrequently occurred or genuinely not realized the extent of them and 2) he thinks it could have been worse. These are obviously problematic and potentially hurtful ideas, but that's one of the things that I want to address. In the story, he's in college, and he's started seeing a therapist for the first time, but he's very reticent to actually describe any of the things troubling him (namely depression, anxiety, and what we would now probably diagnose as C-PTSD) at least partially because he's concerned that they'll reflect poorly on his mother, of whom he feels very protective (for valid but dysfunctional reasons).
Here's the plan:
In the course of the story, he's injured in an accident doing something noble. He gets talked into going to the ER and gets a chest x-ray (because he hit the curb and landed hard on his ribs), and while the doctor is showing him the film to reassure him that his ribs are not broken (while still encouraging him to rest because they're pretty badly bruised), he mentions a couple of healed breaks. The character was unaware that he'd ever had a rib fracture in that area, though he'd suspected, after a relatively recent event, that he might have broken a rib on the other side; he didn't seek treatment for it, so he never got an x-ray to be sure. The recent incident was within the previous two years and occurred following puberty, so I'm assuming that it's still clearly visible on the x-ray. But my question concerns the other healed posterior fracture, in one of the 9th or 10th ribs, that would have occurred maybe eight years prior, around the age of twelve, from being slammed into a wall or to the ground with considerable but not extreme force.
From the research I was able to do, I've gathered that it's not uncommon to have a simple rib fracture and not realize, particularly in the lower ribs, and that these are occasionally found years after the fact on x-ray while looking for something else, with patients sometimes reporting no memory of how it could have occurred. So it seems like a case could be made for that sort of reveal. But because of the greater remodeling potential in childhood, I'm wondering how realistic this is? I've seen some sources claiming that a healed childhood fracture will virtually be undetectable and others claiming that it can be seen, especially depending on how it heals and whether there are any complicating factors. I figure since the fracture was missed and there were a lot of pressures on this kid, he didn't rest, so that may have aggravated and thus lengthened or complicated the healing of the initial rib injury. This is a character with a fairly high pain tolerance and some level of disconnect from his body even at that age, so I think there’s some leeway in terms of whether he might realistically not clock how bad it is, as long as he’s still functional.
Basically, I'm trying to find the line between a childhood injury severe enough to be detectable almost a decade later in adulthood (by a highly skilled and particularly observant radiologist who's really looking at the ribs specifically, so more likely to catch it) and one not so severe that it would have been too unrealistic for it to go unnoticed or that would have caused complications and further injury if left untreated. I'm also wondering if fractures that healed in childhood look in any way visibly distinct from fractures that healed in adulthood or if the older healed injury would look much different from the more recent fracture (eight years versus two years out from the initial injuries), simply because it's had more time to heal, and thus be distinguishable (because while I gather that it's difficult to date injuries via radiography, I wonder if relative age could be determined--like, maybe they can't say when it happened, but they can say that this one's older than that one at least). And if so, how a doctor might describe this to a patient.
The conclusion I want him to come to is that, realistically, the only explanation for the older/other fracture is the abuse (either because it’s clearly older than the fracture caused by the more recent event or because it’s in a different area that he doesn’t specifically recall injuring). He remembers one incident in particular, after which he had trouble bending down to tie his shoes or picking up his younger sibling without significant pain for some time, and assumes that that was likely the event. Because his mother was recovering from pneumonia that winter and was already overworked and overburdened to begin with, she missed it, and he didn’t say anything because he didn’t want to worry her and he was already used to hiding discomfort/his problems by then (which is another realization he’s going to contend with).
The idea is that it's shocking to him that the physical abuse was more severe than he'd realized--that it actually was "that bad", even though he wasn't being beaten and, in his mind, that’s how he conceptualizes abuse--but that the realization doesn't actually change his feelings about what occurred or his relationship with the abusive parent. If he'd never learned about the injury, the damage would still have been done, you know? The severity isn't what made it wrong and hurtful. This sort of forces him to reframe his experiences and reflect on how he'd minimized what happened, and it brings him closer to understanding the many forms abuse can take--that it's not all about the physical damage. The end result of this is that he brings it up in therapy, with the intention of finally being honest about some of the things that have been troubling him, though he's now very concerned that the therapist will judge his mother for not having noticed her kid walking around with broken ribs.
Anyway, I realize that some of this is being exaggerated for dramatic effect, but is this a scenario that’s completely unworkable? I'm not married to the particulars of it, but the underlying idea is sort of pivotal for character development at that juncture of the story.
