Basics
Description
- Result of major or minor thoracic trauma
- Can be classified as traumatic or pathologic
Etiology
- Blunt thoracic trauma:
- Simple fall, fall from height
- Motor vehicle crash
- Assault
- Missile
- CPR-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, throwing
- Severe cough
- Pathologic fractures associated with minor trauma or significant underlying disease:
- Advanced age
- Osteoporosis
- Neoplasm
- 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 usage
- Steering wheel damage
- Air 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:
- Pneumothorax
- Hemothorax
- Pneumomediastinum
- Pulmonary contusion
- Atelectasis
- Widened mediastinal silhouette
- Pulmonary 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 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
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 pneumonia
- Intercostal nerve blocks with 0.5% bupivacaine are safe and effective:
- Provides 6 " 12 hr of pain relief
- Intercostal 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 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.
Medication
- 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)
- 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 " 6h
- Acetaminophen: 325 mg/hydrocodone 2.5 " 10 mg PO q4 " 6h
- Acetaminophen: 325 mg/oxycodone 2.5 " 10 mg PO q4 " 6h
- 2nd line: For PO intolerance or more severe pain
- Hydromorphone: 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 pain
- Oversedation
- Hypoventilation 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 breath
- Increased pain
- Inadequate pain control
- Fever
- Cough
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)