Rib fracture

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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

Clinical Features

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

Differential Diagnosis

Thoracic Trauma

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

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

  • 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

See Also

References

  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.