Rib fracture

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
- Ribs more flexible in children, so fractures require extreme force
- Consider non-accidental trauma

Clinical Features

Chest wall pain
May have chest wall crepitus or ecchymosis
Pain on inspiration

Differential Diagnosis

Thoracic Trauma

Airway/Pulmonary
Cardiac/Vascular
- Cardiac injury
- Traumatic aortic transection
Musculoskeletal
Other

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

Adequate analgesia
Incentive spirometry

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

≥ 65 years of age
3-5 uncomplicated rib fractures
RR > 18/min despite adequate pain control
Incentive spirometry < 75% of predicted
Unable to control pain with oral medications

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

ICU

Severe rib fractures (e.g., > 5 ribs, multiple displaced fractures, flail chest)
Signs of significant respiratory compromise (e.g., SpO2 < 92%)
Risk of respiratory decompensation (e.g., older age, COPD, neuromuscular disease)
Discretion of clinician managing patient

References

↑ 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.
↑ 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.
↑ 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
↑ 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.

Authors:

[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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