Rib fracture

Background

Multiple Right sided rib fractures

• Diagnostic goal
  • Detect commonly associated conditions: hemopneumothorax, pneumothorax, pulmonary contusion, intra-abdominal injury, major vascular injury
• Pediatrics
  • <2 years old with >2 rib fractures = 50% mortality
  • Ribs more flexible in children, so fractures require extreme force
  • Always consider non accidental trauma
• Elderly
  • Double the mortality of younger patients

Clinical Features

• Rib pain
• Assess for flail chest

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragm injury
  • Hemothorax
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac contusion
  • Cardiac trauma
  • Cardiac tamponade
  • Commotio cordis
    • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Flail chest
  • Rib fracture
  • Scapula fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Traumatic asphyxia

Evaluation

• CXR (Consider xray rib views)
  • May only pick up 24% of fractures
  • 9th, 10th, 11th rib fractures associated with intra-abdominal injury
• CT thorax without contrast for more definitive diagnosis
  • Sensitivity 0.63 and specificity 0.97

Management

Admission

• Consider Hydromorphone PCA upon decision to admit
• Incentive spirometry
• Early NSAIDs for multiple rib fractures to reduce pneumonia risk
  • Ibuprofen 800mg IV q6hrs
  • OR Ketorolac 15-30mg IV q6 hrs
  • 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

• Strongly consider admission for more than one rib fracture in elderly patient or patient with preexisting pulmonary disease
  • Difficult for these patients to cough / clear secretions

See Also

• Fracture (Main)

References

Authors

Ross Donaldson