Rib fracture: Difference between revisions
 
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=Background=
==Background==
[[File:multipleribfractures.png|thumbnail|Multiple Right sided rib fractures]]
[[File:Gray530.png|thumb|Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.]]
*Diagnostic goal: detect commonly associated conditions: hemopneumothorax, pulmonary contusion, intra-abdominal injury, major vascular injury
*Most common injury in blunt chest trauma
*Pediatrics: <2 years old with >2 rib fractures = 50% mortality
*9th, 10th, 11th rib fractures associated with intra-abdominal injury
*Elderly patients have double the mortality of younger patients
*<2 years old with >2 rib fractures → 50% mortality
**Ribs more flexible in children, so fractures require extreme force
**Ribs more flexible in children, so fractures require extreme force
*Elderly: double the mortality of younger patients
**Consider [[non-accidental trauma]]


=Diagnosis=
==Clinical Features==
*Chest x-ray
*[[Chest wall pain]]
**1st & 2nd rib fractures associated with severe chest trauma and underlying injury
*May have chest wall crepitus or ecchymosis
**9th, 10th, 11th rib fractures associated with intra-abdominal injury
*Pain on inspiration


==Differential Diagnosis==
==Differential Diagnosis==
{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}


=Disposition=
==Evaluation==
*Strongly consider admission for more than one rib fracture in elderly patient or patient with preexisting pulmonary disease
[[File:Ribs labeled.png|thumb|Ribs labled on [[CXR]].]]
**Difficult for these patients to cough / clear secretions
[[File:multipleribfractures.png|thumbnail|Multiple right-sided acute rib (and clavicle) fractures.]]
*If discharged:
[[File:Fracturedribsmarked.jpg|thumb|[[CXR]] with multiple old/healed fractured ribs of the person's left side (oval).]]
**Teach how to splint and cough
[[File:X-ray of rib fractures and pneumothorax.jpg|thumb|Right sided [[pneumothorax]] with multiple rib fractures.]]
**Be liberal with pain medicine
[[File:BrokenRidCTParaSag.png|thumb|Two broken ribs as seen on parasagittal CT.]]
**Encourage incentive spirometer or tell to blow up balloons
[[File:PMC3259405 13244 2011 72 Fig22 HTML.png|thumb|Coronal CT image showing multiple contiguous left rib fractures (arrows).]]
**Discourage rib belts or straps
===Workup===
''Rib series typically <u>not</u> indicated''
*[[CXR]]
**May only pick up 24% of fractures<ref>Rainer TH, Griffith JF, Lam E, et al. Comparison of thoracic ultrasound, clinical acumen, and radiography in patients with minor chest injury. J Trauma 2004:56;1211–13.</ref>
*CT chest
**Better sensitivity (63%) and specificity (97%)<ref>Schulze C, Hoppe H, Schweitzer W, et al. Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy. Forensic Sci Int. 2013; 233(1-3):90-98.</ref>
*[[Ultrasound]]
**Has been shown to detect rib fractures not seen on radiographs<ref>Turk F, Kurt AB, Saglam S. Evaluation by ultrasound of traumatic rib fractures missed by radiography. Emerg Radiol. 2010;17(6):473-477. doi:10.1007/s10140-010-0892-9</ref>
 
===Diagnosis===
*Typically made on imaging (see above)
*Consider [[flail chest]], if multiple ribs are fractured in 2 or more places and paradoxical chest wall movement
 
==Management==
*Adequate [[analgesia]]
*Incentive spirometry
 
===NOT Indicated===
*Rib belts or other chest wall wrapping has no place in treatment and should be discouraged
 
==Disposition==
===Discharge===
*Consider for:
**Isolated rib fractures
**Young, otherwise healthy patient
**Good respiratory effort and cough (able to clear respiratory secretions)
**Pain controlled with PO medications
 
===Admission===
*≥ 65 years of age
*3-5 uncomplicated rib fractures
*RR > 18/min despite adequate pain control
*Incentive spirometry < 75% of predicted
*Unable to control pain with oral medications
 
*Consider for:
**Elderly patient with multiple rib fractures, hypotension, pulmonary contusion, hemothorax, pneumothorax, or age >85<ref>Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL, Ahmed SS. Factors associated with complications in older adults with isolated blunt chest trauma. West J Emerg Med. 2009 May. 10(2):79-84.</ref>
**[[Flail chest]]
**Significant associated injury
**Pre-existing pulmonary disease
 
===ICU===
*Severe rib fractures (e.g., > 5 ribs, multiple displaced fractures, flail chest)
*Signs of significant respiratory compromise (e.g., SpO2 < 92%)
*Risk of respiratory decompensation (e.g., older age, COPD, neuromuscular disease)
*Discretion of clinician managing patient


==See Also==
==See Also==
*[[Pulmonary Contusion]]
*[[Traumatic Pneumothorax]]
*[[Sternum Fracture]]
*[[Fracture (Main)]]
*[[Fracture (Main)]]
*[[Flail chest]]


==Source==
==References==
*Tintinanlli
<references/>


[[Category:Pulm]]
[[Category:Pulmonary]]
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 02:13, 30 October 2024

Background

Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.
  • Most common injury in blunt chest trauma
  • 9th, 10th, 11th rib fractures associated with intra-abdominal injury
  • Elderly patients have double the mortality of younger patients
  • <2 years old with >2 rib fractures → 50% mortality

Clinical Features

  • Chest wall pain
  • May have chest wall crepitus or ecchymosis
  • Pain on inspiration

Differential Diagnosis

Thoracic Trauma

Evaluation

Ribs labled on CXR.
Multiple right-sided acute rib (and clavicle) fractures.
CXR with multiple old/healed fractured ribs of the person's left side (oval).
Right sided pneumothorax with multiple rib fractures.
Two broken ribs as seen on parasagittal CT.
Coronal CT image showing multiple contiguous left rib fractures (arrows).

Workup

Rib series typically not indicated

  • CXR
    • May only pick up 24% of fractures[1]
  • CT chest
    • Better sensitivity (63%) and specificity (97%)[2]
  • Ultrasound
    • Has been shown to detect rib fractures not seen on radiographs[3]

Diagnosis

  • Typically made on imaging (see above)
  • Consider flail chest, if multiple ribs are fractured in 2 or more places and paradoxical chest wall movement

Management

NOT Indicated

  • Rib belts or other chest wall wrapping has no place in treatment and should be discouraged

Disposition

Discharge

  • Consider for:
    • Isolated rib fractures
    • Young, otherwise healthy patient
    • Good respiratory effort and cough (able to clear respiratory secretions)
    • Pain controlled with PO medications

Admission

  • ≥ 65 years of age
  • 3-5 uncomplicated rib fractures
  • RR > 18/min despite adequate pain control
  • Incentive spirometry < 75% of predicted
  • Unable to control pain with oral medications
  • Consider for:
    • Elderly patient with multiple rib fractures, hypotension, pulmonary contusion, hemothorax, pneumothorax, or age >85[4]
    • Flail chest
    • Significant associated injury
    • Pre-existing pulmonary disease

ICU

  • Severe rib fractures (e.g., > 5 ribs, multiple displaced fractures, flail chest)
  • Signs of significant respiratory compromise (e.g., SpO2 < 92%)
  • Risk of respiratory decompensation (e.g., older age, COPD, neuromuscular disease)
  • Discretion of clinician managing patient

See Also

References

  1. ↑ Rainer TH, Griffith JF, Lam E, et al. Comparison of thoracic ultrasound, clinical acumen, and radiography in patients with minor chest injury. J Trauma 2004:56;1211–13.
  2. ↑ Schulze C, Hoppe H, Schweitzer W, et al. Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy. Forensic Sci Int. 2013; 233(1-3):90-98.
  3. ↑ Turk F, Kurt AB, Saglam S. Evaluation by ultrasound of traumatic rib fractures missed by radiography. Emerg Radiol. 2010;17(6):473-477. doi:10.1007/s10140-010-0892-9
  4. ↑ Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL, Ahmed SS. Factors associated with complications in older adults with isolated blunt chest trauma. West J Emerg Med. 2009 May. 10(2):79-84.
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