Rib fracture

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Background

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Multiple Right sided rib fractures

Clinical Features

  • Rib pain
  • Assess for flail chest

Differential Diagnosis

Thoracic Trauma

Evaluation

  • CXR (Consider xray rib views)
    • May only pick up 24% of fractures[1]
    • 9th, 10th, 11th rib fractures associated with intra-abdominal injury
  • CT thorax without contrast for more definitive diagnosis
    • Sensitivity 0.63 and specificity 0.97[2]

Management

Admission

  • Consider Hydromorphone PCA upon decision to admit[3]
  • Incentive spirometry
  • Early NSAIDs for multiple rib fractures to reduce pneumonia risk
  • Transition to PO opioids and NSAIDs whenever possible
  • Consider addition of:
    • Positive airway pressure system (e.g. EzPAP®)
    • Continuous epidural Bupivacaine infusion if failure of PCA/NSAIDs
    • Paracostal infusions of Bupivacaine via elastomeric pump (ex. On-Q or C-Bloc)
    • Ultrasound guided Serratus plane block with long acting anesthetic
    • Diazepam 10mg IV/PO q4-6 hrs if respiratory rate adequate

Discharge

  • Teach how to splint and cough
  • Be liberal with pain medicine
  • Encourage incentive spirometer or tell to blow up balloons
  • Discourage rib belts or straps

Disposition

  • Strongly consider admission for more than one rib fracture in elderly patient or patient with preexisting pulmonary disease
    • Difficult for these patients to cough / clear secretions

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. Dept of Surg Edu at Orlando Regional Medical Center. Multi-modality pain control for rib fractures. Surgical Critical Care. 11/30/2010. http://www.surgicalcriticalcare.net/Guidelines/rib%20fracture%202010.pdf
  4. Yang Y et al. Use of ketorolac is associated with decreased pneumonia following rib fractures. Am J Surg. 2014 Apr;207(4):566-72. doi: 10.1016/j.amjsurg.2013.05.011. Epub 2013 Oct 7.