Difference between revisions of "Rib fracture"

(Text replacement - "OR" to "'''OR'''")
 
Line 1: Line 1:
 
==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]], [[pneumothorax]], [[pulmonary contusion]], [[intra-abdominal injury]], major [[vascular injury]]
+
*Most common injury in blunt chest trauma
*Pediatrics
+
*9th, 10th, 11th rib fractures associated with intra-abdominal injury
**<2 years old with >2 rib fractures = 50% mortality
+
*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
**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==
Line 18: Line 19:
  
 
==Evaluation==
 
==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
*Early [[NSAIDs]] for multiple rib fractures to reduce [[pneumonia]] risk
+
*If flail segment is present, positive pressure ventilation may be required to allow for adequate ventilation
**[[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:
 
**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==
 
==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==

Latest 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.