II. Pathophysiology

  1. Rib Fractures are most common at posterolateral bend (weakest point)
  2. Most common ribs Fractured are the fourth and ninth ribs

III. Precautions: Children

  1. Force must be substantial to cause pediatric Rib Fractures
    1. Pediatric chest wall is compliant
    2. Evaluate for serious intrathoracic injury
  2. Posteromedial Rib Fractures
    1. Evaluate for non-accidental trauma
    2. Suspect non-accidental trauma especially under age 18 months with multiple Fractures at variable stages of healing

IV. Causes

  1. Blunt chest trauma (most common cause)
    1. Children and teens
      1. Non-accidental trauma
      2. Sports injury
    2. Young adults
      1. Motor vehicle accident
    3. Elderly
      1. Fall from standing height
      2. Cardiopulmonary Resuscitation
  2. Pathologic Rib Fracture
    1. Cancer
    2. Osteoporosis
  3. Stress Fracture
    1. Cough fracture
    2. High-level athlete with repetitive activities involving chest musculature
      1. Rowing
      2. Throwing
      3. Weight lifting
    3. Higher risk sports
      1. Basketball
      2. Gymnastics
      3. Swimming

V. Signs

  1. Focal point tenderness over rib
    1. Referred pain along rib course
  2. Bony crepitus over Fracture
  3. Ecchymosis, abrasions or swelling over Rib Fracture
  4. Complication findings
    1. Unilateral decreased or absent breath sounds on affected side (Pneumothorax or Splinting and Atelectasis)
    2. Focal neurologic deficit over trunk or upper extremities
    3. Pneumothorax signs
    4. Flail Chest signs
    5. Intraabdominal injury (especially ribs 10-12)

VI. Approach: Rib levels

  1. Ribs 1 to 3
    1. Associated with high energy injury (risk of concurrent intrathoracic injuries)
    2. Direct injury to underlying intravascular injury
  2. Ribs 4 to 10
    1. Most commonly Fractured ribs (especially 4 and 9)
    2. Risk of Pneumothorax
  3. Ribs 10 to 12
    1. Risk of intraabdominal injury (liver, Spleen, Kidney and diaphragm)

VII. Red Flags: High risk Rib Fractures

  1. Injuries suggestive of high energy injury
    1. Rib Fracture at 1 to 3
    2. Sternum Fracture
    3. Scapular Fracture
    4. Young patient with more than one Rib Fractured
    5. Significant Mechanism (Fall from height >20 feet, crushing injury, motorcycle accident)
  2. Injuries with risk of neurovascular injury
    1. Rib Fracture at 1 to 3
  3. Injuries with risk of abominal injury (liver, Spleen, Kidney and diaphragm)
    1. Rib Fracture at 10 to 12

VIII. Imaging: Chest

  1. Precaution
    1. Rib Fracture is a clinical diagnosis based on injury mechanism and exam findings (e.g. focal, exquisite rib tenderness)
    2. Imaging can confirm Rib Fracture, but is not required
    3. Imaging chief role is to evaluate serious complications from chest trauma as well as from Rib Fractures
  2. Approach
    1. Major Trauma (high risk mechanism of injury)
      1. CT Chest (to evaluate more serious concurrent injuries such as aortic injury)
    2. Minor Trauma
      1. Chest XRay
      2. Consider Rib Ultrasound
      3. Consider Chest CT if non-diagnostic Chest XRay and:
        1. Symptomatic patient of more serious intrathoracic injury or
        2. XRay with suspicious findings
          1. Hemothorax or large Pneumothorax
          2. Wide mediastinum (>8cm)
          3. Multiple Rib Fractures or Flail Chest
          4. Fractured Sternum or Fracture of ribs 1 or 2
        3. Other possible indications for Chest CT and nondiagnostic Chest XRay
          1. Definitive Rib Fracture on imaging would alter management
          2. Rib Fracture is a clinical diagnosis and chest CT is not recommended solely for definitive Rib Fracture diagnosis
    3. Minimal trauma with normal Vital Signs, exam and adequate pain control
      1. Chest XRay is optional
  3. Chest XRay (preferred first line test in most cases)
    1. Rib Fracture
      1. Test Sensitivity for Rib Fracture: 50%
      2. Turn XRay on its side (use software rotation)
        1. Follow arch lines of both anterior and posterior aspects of the ribs
        2. Fracture lines are more evident in this view
    2. Pneumothorax
      1. Especially with Rib Fractures at 4-9
      2. Consider expiratory Chest XRay
    3. Hemothorax
    4. Pulmonary Contusion
    5. Widened mediastinum
  4. Rib XRay (Rib Detail Films)
    1. Disadvantages
      1. Adds little to evaluation in most cases beyond standard two view Chest XRay
      2. Rib Fractures are a clinical diagnosis, and rib films add nothing to a good history and exam for Rib Fracture
      3. More accurate modalities are preferred if definitive diagnosis required (rib Ultrasound, CT Chest)
    2. Indications
      1. Consider in minor trauma where Chest XRay is non-diagnostic and definitive diagnosis of Rib Fracture will alter management
      2. Consider in suspected Rib Fracture at ribs 1-3 and 9-12 in which cases confirmed Rib Fracture would prompt advanced imaging
    3. References
      1. Sadhna (1995) Emerg Radiol 2(5): 264-6
  5. CT Chest
    1. Gold standard in chest trauma (but is not recommended for diagnosis of Rib Fracture alone, which should be made clinically)
    2. Indicated for high risk injury as listed above under red flags
    3. Defines high risk injuries (e.g. vascular injuries)
      1. Suspected Thoracic vascular injuries are the primary indication for Chest CT in trauma)
      2. Also defines Rib Fractures as well as Lung Contusion, Pneumonia, Pneumothorax, and Hemothorax
    4. CT Angiography indications (suspected vascular injury, especially aorta)
      1. Fracture of ribs 1 or 2
      2. Wide mediastinum (>8 cm)
      3. Left Pleural Effusion
      4. Tracheal deviation to right
      5. Apical cap
      6. Left main stem Bronchus decompression
  6. Rib Ultrasound
    1. Indications
      1. Emerging as viable modality for bedside Rib Fracture evaluation
    2. Disadvantages
      1. Time consuming for clinician and painful for patient
      2. Certain ribs may be more difficult to image
    3. Technique
      1. Use high frequency linear probe along the bony contour of the rib
      2. Fracture should appear as a break in the hyperechoic line at the bony surface
    4. References
      1. Turk (2010) Emerg Radiol 17(6):473-7

IX. Imaging: Other studies

  1. FAST Exam
    1. Evaluate for intra-abdominal Hemorrhage (hepatorenal margin, splenorenal margin)
    2. Evaluate for Pneumothorax and Pleural Effusion (possible Hemothorax)
  2. CT Abdomen
    1. Indicated for Rib Fracture at 10-12 and abdominal exam suggestive of injury
    2. Evaluate for liver Laceration and splenic rupture

X. Management

  1. Trauma surgeon consult if high risk, high energy injury (see red flags above)
  2. Pain management to decrease Splinting and improve ventilation (single most important intervention)
    1. Narcotic Analgesics
    2. Intercostal block
    3. Epidural Anesthesia
  3. Incentive spirometer
    1. No evidence of benefit, but unlikely to cause harm
    2. Use 10 times every 1-2 hours while awake for at least 1 week or until pain is minimal
  4. Discharge indications
    1. Young patient under age 65 years and
    2. Two or less Rib Fractures and
    3. No lung parenchymal injury and no Abdominal Injury and
    4. No comorbidity and
    5. Adequate pain control on Oral Analgesics
  5. Follow-up
    1. Educate patients on warning signs
      1. Delayed Hemothorax occurs in 4-7% of cases (rare without multiple or displaced Rib Fractures)
      2. Delayed Pneumothorax occurs in 2-5% of cases
      3. Pneumonia occurs in up to 31% of elderly with Rib Fractures
      4. Non-union can occur
    2. Immediate re-evaluation
      1. Shortness of Breath
      2. Increasing pain
      3. Productive cough
      4. Fever
    3. Not improving
      1. Follow-up in 48 to 72 hours
    4. Routine re-evaluation
      1. Follow-up in 1-2 weeks for pain management
      2. Expect 6 weeks for complete healing
  6. Hospitalization indications
    1. Older patients
      1. Especially consider admission if debilitated or serious comorbidity (COPD, CAD, liver or renal disease)
      2. Higher risk of Atelectasis and secondary Pneumonia (up to 31% secondary PneumoniaIncidence in elderly)
      3. Stawicki (2004) J Am Geriatr Soc 52: 805-8
    2. Rib Fractures and comorbidity (e.g. underlying heart or lung disease)
    3. Intractable pain requiring parenteral Opioids
    4. Multiple Rib Fractures
      1. Three or more Rib Fractures in patients over 65 years
      2. Five or more Rib Fractures at any age
      3. Flail Chest
    5. Intrathoracic or extrathoracic secondary injury
      1. High risk injuries (see red flags above)
      2. Lung Contusion or other parenchymal injury
      3. Liver or Spleen injury
    6. Pediatric Rib Fractures (especially displaced or multiple)
      1. Associated with high energy injury and high risk of intrathoracic injury
      2. Consider admission to Pediatric Trauma service
      3. Consider nonaccidental trauma (especially multiple, under 18 months old and posteromedial Rib Fractures)

XI. Prognosis: Mortality risk factors

  1. Severe mechanism of injury (with secondary intrathoracic injury)
  2. Age 65 or older
    1. Twice mortality of younger patients
    2. Mortality increases as much as 19% with each successive Rib Fracture
  3. More than 5 Fractured ribs
  4. Age 46-65 years old

XII. Complications

  1. Pain induced Splinting complications
    1. Increased risk with underlying comorbidity (e.g. COPD, CAD, liver or Kidney disease or Dementia)
    2. Atelectasis (due to Splinting)
    3. Pneumonia
  2. Rib Fracture at ribs 1 to 3
    1. Neurovascular injury
    2. High energy injury (ribs 1-3 Fractured or sternal Fracture, Scapula Fracture)
      1. Lung Contusion
      2. Cardiac Contusion
      3. High mortality risk
  3. Rib Fracture at ribs 4 to 9 (most commonly injured ribs)
    1. Pneumothorax
    2. Hemothorax
    3. Lung Contusion
    4. Flail Chest
  4. Rib Fracture at ribs 10 to 12
    1. Liver Laceration
    2. Splenic rupture
    3. Renal Injury
  5. High energy injury (Rib Fracture 1-3, sternum Fracture, Scapula Fracture)
    1. Lung Contusion
    2. Cardiac Contusion
    3. High mortality risk

XIII. References

  1. Bhavnagri (2009) Clev Clin J Med 76(5):309-14
  2. Jaber (2013) Crit Dec Emerg Med 27(3): 12-17
  3. Livingston (2008) J Trauma 64(4): 905-11

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