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
*Most common injury in blunt chest trauma
***Hemopneumothorax, PTX, pulmonary contusion, intra-abdominal injury, major vascular injury
*9th, 10th, 11th rib fractures associated with intra-abdominal injury
*Pediatrics
*Elderly patients have double the mortality of younger patients
**<2 years old with >2 rib fractures = 50% mortality
*<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
**Always consider non accidental trauma
**Consider [[non-accidental trauma]]
*Elderly
**Double the mortality of younger patients


==Clinical Features==
==Clinical Features==
*Rib pain
*Chest wall pain
*Assess for flail chest
*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==
==Differential Diagnosis==
{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}


==Diagnosis==
==Evaluation==
*CXR (Consider xray rib views)
*[[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>
**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>
**9th, 10th, 11th rib fractures associated with intra-abdominal injury
*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>
*CT thorax without contrast for more definitive diagnosis
**Sensitivity 0.63 and specificity 0.97<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>


==Management==
==Management==
===Admission===
*Adequate analgesia is paramount to management of rib fractures
*Consider [[Hydromorphone]] PCA upon decision to admit<ref>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</ref>
*Rib belts or other chest wall wrapping has no place in treatment and should be discouraged
*Incentive spirometry
*Incentive spirometry
*EzPAP® positive airway pressure system
*If flail segment is present, positive pressure ventilation may be required to allow for adequate ventilation
*Early NSAIDs for multiple rib fractures to reduce pna
**[[Ibuprofen]] 800 mg IV q6hrs
**OR [[Ketorolac]] 15-30 mg IV q6 hrs<ref>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.</ref>
**Limit IV NSAIDs to maximum of 5 days
*Transition to PO narcotics and NSAIDs whenever possible
*Consider addition of:
**Continuous epidural [[Bupivacaine]] infusion if failure of PCA/NSAIDs
**Paracostal infusions of Bupivacaine via elastomeric pump (ex. On-Q or C-Bloc)
**[[Diazepam]] 10 mg 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==
==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
**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<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==
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<references/>
<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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