Rib fractures



Background

  • Common injuries and may be very significant
  • Complications often due to inadequate analgesia/ventilation (atelectasis)
  • Substantial ↑ risk in elderly and pre-existing lung disease
  • Beware occult neighbouring injuries (e.g. vertebral # in blunt injury)

Probability of developing complications
Risk score Probability mean ± SD
0 - 10 13% ± 6
11 - 15 29% ± 8
16 - 20 52% ± 8
21 - 25 70% ± 6
26 - 30 80% ± 6
31+ 88% ± 7
From Battle C, Hutchings H, Lovett S, et al. (below)

Please use the calculator to gain advice on management.

Estimate complication risk and management advice.

Result:


Clinical

Causes

  • Blunt e.g. MVAs, assault, falls
  • Penetrating e.g. stabbing
  • Coughing spells
  • Non accidental injury
  • Stress fractures in athletes

Symptoms

  • Pleuritic pain (worse on movement of the torso, or the arms)
  • SoB
  • Haemoptysis

Signs

  • Localized pain and tenderness
  • Hypoxia, respiratory distress
  • ↑RR & use accessory muscles
  • Palpable or visible deformity
  • Paradoxical chest movements
  • Tracheal deviation (very late)
  • Surgical emphysema
  • Percussion abnormalities

Complications

  • Flail chest affects respiratory mechanics and increases work of breathing
  • Haemothorax
  • Pneumothorax
  • Pulmonary Contusions evolve over the first 48 to 72 hours
  • Superior vena caval obstruction
  • Hepatosplenic injury - high degree of suspicion in lower rib fractures
  • Cardiac contusions
  • Mediastinal/Great vessel injury - particularly fractures of the scapula, first or second rib, or the sternum suggest a significant force of injury
  • Oesophageal injury
  • Diaphragmatic injury
  • Atelectasis and Pneumonia which can be a consequence of inadequate analgesia and sputum clearance

Differential / Consider

Investigations

  • CXR
  • Bedside US
  • CT
  • CT Angiogram
  • Bone Scan
  • MRI
  • OGD or Bronchoscopy

Management

  • The initial goal in the ED is stabilization so remember your ABCDs. This would include resuscitation, insertion of chest drains, transfusion of blood products etc
  • Once stabilized complete your secondary survey to assess for other injuries
  • Relief of pain is important to enable adequate ventilation
  • Intercostal block, epidural anaesthesia, and systemic analgesics
  • Respiratory care including incentive spirometry
  • Utilize the chest injury score and Chest injury referral pathway to assess risk of complications and need for admission, anesthetic or cardiothoracic involvement
  • Provide the patient with verbal and writtenRib Injury Advice
Rib Injury Management Flow Diagram


References

  • Battle C, Hutchings H, Lovett S, Bouamra O, Jones S, Sen A, Gagg J, Robinson D, Hartford-Beynon J, Williams J, Evans A. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. Crit Care. 2014 May 14;18(3):R98. doi: 10.1186/cc13873. PubMed PMID: 24887537; PubMed Central PMCID: PMC4095687

Content by Dr Saema Saeed,Dr Darren McLoughlin and Dr Íomhar O' Sullivan on 11/08/2019. Last review Dr ÍOS 7/09/21.