Rib fracture: Difference between revisions

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==Background==
==Background==
[[File:Gray530.png|thumb|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
**Ribs more flexible in children, so fractures require extreme force
**Consider [[non-accidental trauma]]


==Clinical Features==
*[[Chest wall pain]]
*May have chest wall crepitus or ecchymosis
*Pain on inspiration


*kids <2y w/ >2 rib fx have almost 50% mort b/c ribs in kids rarely break & fx= xtreme force!
==Differential Diagnosis==
{{Thoracic trauma DDX}}


*elderly have 2 X mortality w/ rib fx as younger pts
==Evaluation==
[[File:Ribs labeled.png|thumb|Ribs labled on [[CXR]].]]
[[File:multipleribfractures.png|thumbnail|Multiple right-sided acute rib (and clavicle) fractures.]]
[[File:Fracturedribsmarked.jpg|thumb|[[CXR]] with multiple old/healed fractured ribs of the person's left side (oval).]]
[[File:X-ray of rib fractures and pneumothorax.jpg|thumb|Right sided [[pneumothorax]] with multiple rib fractures.]]
[[File:BrokenRidCTParaSag.png|thumb|Two broken ribs as seen on parasagittal CT.]]
[[File:PMC3259405 13244 2011 72 Fig22 HTML.png|thumb|Coronal CT image showing multiple contiguous left rib fractures (arrows).]]
===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


==Diagnosis==
==Management==
*Adequate [[analgesia]]
*Incentive spirometry


===NOT Indicated===
*Rib belts or other chest wall wrapping has no place in treatment and should be discouraged


*PA CXR highest yield for rib fx, but clinical dx
==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


*1st & 2nd Rib Fx hallmark of severe chest trauma, can injure brach plexus, great vessels & lung, ONLY nd angio if evidence of neurological or vascular injury, studies have shown no incr risk if nv intact & fx pattern & amt of displacement does NOT predict vascular inj
===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


*costochondral seperation have nl cxr w/ similar s/s of rib fx, takes wks to mos to heal d/t decr vasc
*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==
*[[Fracture (Main)]]
*[[Flail chest]]


==References==
<references/>


(Burbulys 2004/Trauma Reports 4/04 /A-Digest 7/04) -by Lampe
[[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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