Rib fracture: Difference between revisions

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=Background=
==Background==
[[File:multipleribfractures.png|thumbnail|Multiple Right sided rib fractures]]
[[File:multipleribfractures.png|thumbnail|Multiple Right sided rib fractures]]
*Diagnostic goal: detect commonly associated conditions: hemopneumothorax, pulmonary contusion, intra-abdominal injury, major vascular injury
 
*Pediatrics: <2 years old with >2 rib fractures = 50% mortality
*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
**Ribs more flexible in children, so fractures require extreme force
*Elderly: double the mortality of younger patients
**Consider [[non-accidental trauma]]
 
==Clinical Features==
*Chest wall pain
*May have chest wall crepitus or ecchymosis
*Pain on inspiration
*Flail segment (paradoxical chest wall movement) may be seen if multiple ribs are fractured in 2 or more places
 
==Differential Diagnosis==
{{Thoracic trauma DDX}}
 
==Evaluation==
*[[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 has much 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>


=Diagnosis=
==Management==
*Chest x-ray
*Adequate analgesia is paramount to management of rib fractures
**1st & 2nd rib fractures associated with severe chest trauma and underlying injury
*Rib belts or other chest wall wrapping has no place in treatment and should be discouraged
**9th, 10th, 11th rib fractures associated with intra-abdominal injury
*Incentive spirometry
*If flail segment is present, positive pressure ventilation may be required to allow for adequate ventilation


=Disposition=
==Disposition==
*Strongly consider admission for more than one rib fracture in elderly patient or patient with preexisting pulmonary disease
*Consider discharge for:
**Difficult for these patients to cough / clear secretions
**Isolated rib fractures
*If discharged:
**Young, otherwise healthy patient
**Teach how to splint and cough
**Good respiratory effort and cough (able to clear respiratory secretions)
**Be liberal with pain medicine
**Pain controlled with PO medications
**Encourage incentive spirometer or tell to blow up balloons
*Consider admission for:
**Discourage rib belts or straps
**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 segment
**Significant associated injury
**Pre-existing pulmonary disease


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


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


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

Revision as of 04:06, 23 October 2017

Background

Multiple Right sided rib fractures
  • 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
  • Flail segment (paradoxical chest wall movement) may be seen if multiple ribs are fractured in 2 or more places

Differential Diagnosis

Thoracic Trauma

Evaluation

  • CXR
    • May only pick up 24% of fractures[1]
  • CT chest has much better sensitivity (63%) and specificity (97%)[2]

Management

  • Adequate analgesia is paramount to management of rib fractures
  • Rib belts or other chest wall wrapping has no place in treatment and should be discouraged
  • Incentive spirometry
  • If flail segment is present, positive pressure ventilation may be required to allow for adequate ventilation

Disposition

  • Consider discharge for:
    • Isolated rib fractures
    • Young, otherwise healthy patient
    • Good respiratory effort and cough (able to clear respiratory secretions)
    • Pain controlled with PO medications
  • Consider admission for:
    • Elderly patient with multiple rib fractures, hypotension, pulmonary contusion, hemothorax, pneumothorax, or age >85[3]
    • Flail segment
    • Significant associated injury
    • Pre-existing pulmonary disease

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. ↑ 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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