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
*Most common injury in blunt chest trauma
**Detect commonly associated conditions: [[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


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


==Diagnosis==
==Evaluation==
*CXR (Consider xray rib views)
[[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>
**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
*CT thorax without contrast for more definitive diagnosis
**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>
**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>
*[[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==
==Management==
===Admission===
*Adequate [[analgesia]]
*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>
*Incentive spirometry
*Incentive spirometry
*EzPAP® positive airway pressure system
*Early NSAIDs for multiple rib fractures to reduce [[pneumonia]] risk
**[[Ibuprofen]] 800mg IV q6hrs
**OR [[Ketorolac]] 15-30mg 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 opioids 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]] 10mg IV/PO q4-6 hrs if respiratory rate adequate


===NOT Indicated===
*Rib belts or other chest wall wrapping has no place in treatment and should be discouraged
==Disposition==
===Discharge===
===Discharge===
*Teach how to splint and cough
*Consider for:
*Be liberal with pain medicine
**Isolated rib fractures
*Encourage incentive spirometer or tell to blow up balloons
**Young, otherwise healthy patient
*Discourage rib belts or straps
**Good respiratory effort and cough (able to clear respiratory secretions)
**Pain controlled with PO medications


==Disposition==
===Admission===
*Strongly consider admission for more than one rib fracture in elderly patient or patient with preexisting pulmonary disease
*Consider for:
**Difficult for these patients to cough / clear secretions
**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


==See Also==
==See Also==
*[[Fracture (Main)]]
*[[Fracture (Main)]]
*[[Flail chest]]


==References==
==References==

Latest revision as of 13:17, 10 April 2021

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

  • 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

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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