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Rib Fracture, Emergency Medicine

Basics

Description

- Blunt thoracic trauma by any mechanism - Mechanism as described by patient, parent, or pre-hospital personnel: - Seat belt usage - Steering wheel damage - Air bag deployment

- Anteroposterior (AP) and lateral chest films are used routinely to diagnose rib fractures - Chest radiography is indicated to rule out associated intrathoracic injury but can miss up to 50% of rib fractures: - May reveal associated intrathoracic pathology: - Pneumothorax - Hemothorax - Pneumomediastinum - Pulmonary contusion - Atelectasis - Widened mediastinal silhouette

- Rib contusion or intercostal muscle strain - Pneumothorax - Costochondral separation - Sternal fracture and dislocation - Nontraumatic causes of chest pain: - Cardiovascular: - Myocardial ischemia or infarction - Pericarditis - Aortic dissection - Pulmonary embolism

- Pulmonary: - Embolism - Infections - Inflammation - Barotrauma

- Musculoskeletal: - Costochondritis - Cervical or thoracic spine disease

- GI: - Esophageal reflux or spasm - Mallory " Weiss tear - Biliary or renal colic - Peptic ulcer disease - Gastritis, pancreatitis, hepatitis

- Dermatologic: - Herpes zoster - Chest wall tumor

- Multiple fractures, elderly patients, or significant underlying lung disease: - Pain control and pulmonary toilet - Search for associated injuries; treat exacerbation of underlying lung disease. - Intercostal nerve blocks for multiple fractures are safe and effective providing 6 " 12 hr of pain relief. - For the admitted patient, thoracic epidural analgesia or patient-controlled analgesia (PCA) is effective, with minimal inhibition of respiratory drive.

- 1st Line: NSAIDs with or without opioids - Ibuprofen: 600 mg PO q6h (peds: 5 " 10 mg/kg PO q6 " 8h) - Naproxen: 250 " 500 mg PO q12h (peds: 10 " 20 mg/kg/d PO div. q12h)

- Consider thoracic epidural analgesia: - Patients with intractable pain - Oversedation - Hypoventilation from narcotic analgesics

- Patients with normal pulmonary function, no underlying pulmonary injury, and adequate pain control on oral analgesics - Strict return criteria should be discussed with the patient prior to discharge: - Shortness of breath - Increased pain - Inadequate pain control - Fever - Cough

  • Result of major or minor thoracic trauma
  • Can be classified as traumatic or pathologic

Etiology

  • Blunt thoracic trauma:Simple fall, fall from heightMotor vehicle crashAssaultMissileCPR-related
  • Penetrating trauma is a less likely cause.Ribs usually break at the point of impact or the posterior angle, the structurally weakest region
  • Stress fractures in upper and middle ribs can occur with recurrent, high force movements:Athletic activities: Golf, rowing, throwingSevere cough
  • Pathologic fractures associated with minor trauma or significant underlying disease:Advanced ageOsteoporosisNeoplasm
  • Relatively elastic chest wall makes rib fractures less common in children.
  • Consider nonaccidental trauma for infants and toddlers without appropriate mechanism.
  • Obtain a skeletal survey to assess for other fractures in infants suspected of being abused
  • Elderly are more prone to rib fractures as well as atelectasis, pneumonia, respiratory failure, and other associated complications.
  • Morbidity and mortality are twice that found in younger populations.

Diagnosis

Signs and Symptoms

History

  • Blunt thoracic trauma by any mechanism
  • Mechanism as described by patient, parent, or pre-hospital personnel:Seat belt usageSteering wheel damageAir bag deployment
  • Localized chest wall pain that increases with deep inspiration, coughing, movement
  • Pleuritic chest pain
  • Dyspnea, shortness of breath

Physical Exam

  • Point tenderness
  • Pain referred to fracture site with palpation of the involved rib elsewhere
  • Bony step-off
  • Crepitus
  • Localized edema
  • Erythema
  • Ecchymosis:Impact from seat belt, aka "seat belt sign " or steering wheel associated with motor vehicle accidents
  • Intercostal muscle spasm
  • Splinting respirations
  • Hypoxia, tachypnea, respiratory distress
  • Auscultation shows normal or diminished breath sounds, occasionally an audible click over fracture site.
  • Segmental paradoxical movement of chest suggests flail chest indicating multiple, unattached fractured ribs.

Essential Workup

  • Diagnosis is initially made on clinical grounds and confirmed on imaging studies.
  • Evaluate for injury to underlying structures
  • The 1st 3 ribs are relatively protected and require significant impact to fracture, may indicate intrathoracic injury.
  • Ribs 9 " 12 are relatively mobile; their fracture suggests possible intra-abdominal injury.
  • Multiple rib fractures may be associated with flail chest and pulmonary contusion.
  • Morbidity correlates with degree of injury to underlying structures, number of ribs fractured, and age.

Diagnosis Tests & Interpretation

Lab

ABGs may reveal hypoxemia or elevated alveolar " arterial gradient:

  • Not indicated for simple, uncomplicated rib fractures
  • May consider in patients with multiple rib fractures or pre-existing pulmonary disease

Imaging

  • Anteroposterior (AP) and lateral chest films are used routinely to diagnose rib fractures
  • Chest radiography is indicated to rule out associated intrathoracic injury but can miss up to 50% of rib fractures:May reveal associated intrathoracic pathology:PneumothoraxHemothoraxPneumomediastinumPulmonary contusionAtelectasisWidened mediastinal silhouettePulmonary contusion appears within 6 " 12 hr after injury:Ranges from patchy alveolar infiltrates to frank consolidation
  • Rib radiograph series offer higher sensitivity but are controversial and are often low yield
  • CT is more sensitive for detecting rib fractures and internal injuries.
  • CT of the chest may be required to rule out intrathoracic injuries.
  • CT or US of the abdomen may be required to rule out associated intra-abdominal injuries.
  • Angiography can be used for the detection of vascular injury if signs and symptoms of neurovascular compromise are present:Injury to the 1st and 2nd ribs can be associated with vascular injury, particularly with posterior displacement.
  • Ultrasound is a promising diagnostic tool for evaluating rib fractures, even for cartilaginous injury

Differential Diagnosis

  • Rib contusion or intercostal muscle strain
  • Pneumothorax
  • Costochondral separation
  • Sternal fracture and dislocation
  • Nontraumatic causes of chest pain:Cardiovascular:Myocardial ischemia or infarctionPericarditisAortic dissectionPulmonary embolismPulmonary:EmbolismInfectionsInflammationBarotraumaMusculoskeletal:CostochondritisCervical or thoracic spine diseaseGI:Esophageal reflux or spasmMallory " Weiss tearBiliary or renal colicPeptic ulcer diseaseGastritis, pancreatitis, hepatitisDermatologic:Herpes zosterChest wall tumor

Treatment

Pre-Hospital

Focus on airway maintenance, analgesia, and supplemental oxygen

Initial Stabilization/Therapy

  • For simple fractures, generally no significant stabilization is required.
  • Multiple fractures, elderly patients, or significant underlying lung disease:Manage airway and resuscitate as indicated.Endotracheal intubation indicated for patients with severe hypoxemia (PaO2 <60 mm Hg on room air, <80 mm Hg on 100% O2) or impending respiratory failure

Ed Treatment/Procedures

  • Simple fractures:Pain control:Key to maintaining adequate pulmonary function, avoiding atelectasis and subsequent pneumoniaIntercostal nerve blocks with 0.5% bupivacaine are safe and effective:Provides 6 " 12 hr of pain reliefIntercostal nerve block should be performed posteriorly, 2 " 3 fingerbreadths from the vertebral midline.Inject 0.5 " 1 mL just under the inferior surface of the rib where the neurovascular bundle is located.Aspirate 1st to be certain the intercostal vessels have not been punctured.Deep breathing or incentive spirometry should be encouraged with adequate pain control.Avoid binders or banding of the chest wall because these restrict ventilation and promote atelectasis.
  • Multiple fractures, elderly patients, or significant underlying lung disease:Pain control and pulmonary toiletSearch for associated injuries; treat exacerbation of underlying lung disease.Intercostal nerve blocks for multiple fractures are safe and effective providing 6 " 12 hr of pain relief.For the admitted patient, thoracic epidural analgesia or patient-controlled analgesia (PCA) is effective, with minimal inhibition of respiratory drive.

Medication

  • 1st Line: NSAIDs with or without opioidsIbuprofen: 600 mg PO q6h (peds: 5 " 10 mg/kg PO q6 " 8h)Naproxen: 250 " 500 mg PO q12h (peds: 10 " 20 mg/kg/d PO div. q12h)
  • Opioid analgesics
  • Multiple acetaminophen/opioid analgesic combinations are available; see "Alert " below.Acetaminophen: 300 mg/codeine 30 mg (peds: 0.5 " 1 mg/kg codeine) PO q4 " 6hAcetaminophen: 325 mg/hydrocodone 2.5 " 10 mg PO q4 " 6hAcetaminophen: 325 mg/oxycodone 2.5 " 10 mg PO q4 " 6h
  • 2nd line: For PO intolerance or more severe painHydromorphone: 2 " 8 mg PO q3 " 4h (peds: 0.03 " 0.08 mg/kg PO q4 " 6h)Hydromorphone: 0.5 " 4 mg IV/IM/SC q4 " 6h (peds: 0.03 " 0.08 mg/kg)Morphine sulfate: 2.5 " 10 mg IV/IM/SC q2 " 6h (peds: 0.1 " 0.2 mg/kg)PCA using hydromorphone or morphine sulfate is effective.Bupivacaine 0.5%: 0.5 " 1 mL per injection for intercostal nerve blocks
  • Consider thoracic epidural analgesia:Patients with intractable painOversedationHypoventilation from narcotic analgesics
  • Avoid NSAIDs when contraindicated due to renal insufficiency or GI bleed
  • The dose of acetaminophen/narcotic analgesic combinations is limited by acetaminophens potential for causing hepatic toxicity.Do not exceed 4 g/24h acetaminophen in adults, 5 doses of 10 " 15 mg/kg/24 h acetaminophen in children.

Follow-Up

Disposition

Admission Criteria

  • Intractable pain
  • Inability to cough and clear secretions
  • Compromised pulmonary function
  • Multiple fractures, fractures of the 1st 3 ribs
  • Displaced rib fractures
  • Associated pneumothorax, pneumomediastinum, pulmonary contusion, intra-abdominal or intrathoracic pathology
  • Elderly patients and patients with significant underlying lung disease:Chronic COPD, CHF, pulmonary fibrosis, asthma
  • Inadequate pain control on oral analgesics
  • ICU care for elderly patients with 6 or more rib fractures

Discharge Criteria

  • Patients with normal pulmonary function, no underlying pulmonary injury, and adequate pain control on oral analgesics
  • Strict return criteria should be discussed with the patient prior to discharge:Shortness of breathIncreased painInadequate pain controlFeverCough

Follow-Up Recommendations

  • Most rib fractures heal within 6 wk, but patients should be able to return to regular daily activities much sooner.
  • Routine follow-up chest x-ray are not recommended

Pearls and Pitfalls

  • Be vigilant for the underlying intrathoracic and intra-abdominal pathology that can be associated with rib fractures.
  • Ensuring adequate pain control and ventilation are paramount in the treatment
  • Each successive rib fracture carries added morbidity and mortality
  • Pediatric rib fractures imply significant force and should raise suspicion for nonaccidental trauma

Additional Reading

  • Eckstein M, Henderson SO. Thoracic trauma. In: Marx JA, Hockberger RS, Walls RM, eds. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby Elsevier; 2010.
  • Kaiser M, Whealon M, Barrios C. The clinical significance of occult thoracic injury in blunt trauma patients. Am Surg. 2010;76(10):1063 " 1066.
  • Livingston DH, Shogan B, John P, et al. CT diagnosis of rib fractures and the prediction of acute respiratory failure. J Trauma. 2008;64:905 " 911.
  • Chan SS. Emergency bedside ultrasound for the diagnosis of ribfractures. Am J Emerg Med. 2009;27:617 " 620.

Codes

ICD9

  • 733.19 Pathologic fracture of other specified site
  • 807.00 Closed fracture of rib(s), unspecified
  • 807.09 Closed fracture of multiple ribs, unspecified
  • 807.4 Flail chest
  • 807.01 Closed fracture of one rib
  • 807.02 Closed fracture of two ribs
  • 807.03 Closed fracture of three ribs
  • 807.04 Closed fracture of four ribs
  • 807.05 Closed fracture of five ribs
  • 807.06 Closed fracture of six ribs
  • 807.07 Closed fracture of seven ribs
  • 807.08 Closed fracture of eight or more ribs
  • 807.0 Closed fracture of rib(s)

ICD10

  • M84.48XA Pathological fracture, other site, init encntr for fracture
  • S22.39XA Fracture of one rib, unsp side, init for clos fx
  • S22.49XA Multiple fractures of ribs, unsp side, init for clos fx
  • S22.5XXA Flail chest, initial encounter for closed fracture
  • S22.31XA Fracture of one rib, right side, init for clos fx
  • S22.32XA Fracture of one rib, left side, init for clos fx
  • S22.41XA Multiple fractures of ribs, right side, init for clos fx
  • S22.42XA Multiple fractures of ribs, left side, init for clos fx
  • S22.43XA Multiple fractures of ribs, bilateral, init for clos fx

SNOMED

  • 33737001 Fracture of rib (disorder)
  • 268029009 pathological fracture (disorder)
  • 1261007 Fracture of multiple ribs (disorder)
  • 78011002 Flail chest (disorder)
  • 14675005 Fracture of seven ribs (disorder)
  • 14950009 Fracture of six ribs (disorder)
  • 20274005 Fracture of one rib (disorder)
  • 31693001 Fracture of two ribs (disorder)
  • 443165006 Pathological fracture due to osteoporosis (disorder)
  • 46043003 Fracture of eight OR more ribs (disorder)
  • 51760006 Fracture of four ribs (disorder)
  • 57577003 Fracture of three ribs (disorder)
  • 68650003 Fracture of five ribs (disorder)