Rib Fracture

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Pathophysiology

Rib Fractures are most common at posterolateral bend (weakest point)
Most common ribs Fractured are the fourth and ninth ribs

Precautions
General

Risks associated with Rib Fractures are often under estimated despite their significant risk of morbidity (esp. older patients)
Complications may be delayed (e.g. Hemothorax, Pneumothorax, Pneumonia)
Pain control is critical to reduce the risk of Splinting, Atelectasis and secondary Pneumonia

Precautions
Children

Force must be substantial to cause pediatric Rib Fractures
1. Pediatric chest wall is compliant
2. Evaluate for serious intrathoracic injury
Posteromedial Rib Fractures
1. Evaluate for Non-accidental Trauma
2. Suspect Non-accidental Trauma especially age <18 months with multiple Fractures at variable stages of healing

Causes

Blunt Chest Trauma (most common cause)
1. Children and teens
  1. Non-accidental Trauma
  2. Sports Injury
2. Young adults
  1. Motor Vehicle Accident
3. Elderly
  1. Fall from standing height
  2. Cardiopulmonary Resuscitation
Pathologic Rib Fracture
1. Cancer
2. Osteoporosis
Stress Fracture
1. Cough fracture
2. High-level athlete with repetitive activities involving chest musculature
  1. Rowing
  2. Throwing
  3. Weight lifting
3. Higher risk sports
  1. Basketball
  2. Gymnastics
  3. Swimming

Signs
General

Decreased inspiration volume (Splinting)
Focal point tenderness over rib
1. Referred pain along rib course
Bony crepitus over Fracture
Ecchymosis, abrasions or swelling over Rib Fracture
Rib Springing Test
1. Pressure applied between one hand applied to anterior chest and the other hand applied from posterior chest
2. Reproduces pain and crepitation at the affected rib

Signs
Complication findings

Unilateral decreased or absent breath sounds on affected side (Pneumothorax, Splinting and Atelectasis)
Focal neurologic deficit over trunk or upper extremities
Pneumothorax signs
Flail Chest signs
Intraabdominal injury (especially ribs 10-12)

Approach
Rib levels

Ribs 1 to 3
1. Associated with high energy injury (risk of concurrent intrathoracic injuries)
2. Direct injury to underlying neurovascular structures (esp. first rib)
  1. Brachial Plexus
  2. Subclavian artery and subclavian vein
3. First Rib Fractures may also occur with fall on outstretched arm or direct Shoulder Trauma
4. Presents with pain at posterior Scapula, Shoulder or base of neck
Ribs 4 to 10
1. Most commonly Fractured ribs (especially 4 and 9)
2. Risk of Pneumothorax
Ribs 10 to 12
1. Risk of intraabdominal injury (liver, Spleen, Kidney and diaphragm)

Red Flags
High risk Rib Fractures

Injuries suggestive of high energy injury
1. Rib Fracture at 1 to 3
2. Sternal Fracture
3. Scapular Fracture
4. Young patient with more than one Rib Fractured
5. Significant Mechanism (Fall from height >20 feet, crushing injury, motorcycle accident)
Injuries with risk of neurovascular injury
1. Rib Fracture at 1 to 3
Injuries with risk of abominal injury (liver, Spleen, Kidney and diaphragm)
1. Rib Fracture at 10 to 12

Imaging
Chest

Precaution
1. Rib Fracture is a clinical diagnosis based on injury mechanism and exam (e.g. focal, exquisite rib tenderness)
2. Imaging can confirm Rib Fracture, but is not required
3. Imaging chief role is to evaluate serious complications from Chest Trauma as well as from Rib Fractures
Approach
1. Consider decision rules
  1. See Nexus Chest CT Decision Rule in Blunt Trauma
2. Major Trauma (high risk mechanism of injury)
  1. CT Chest (to evaluate more serious concurrent injuries such as aortic injury)
3. Minor Trauma
  1. Chest XRay
  2. Consider Rib Ultrasound
  3. Consider Chest CT if non-diagnostic Chest XRay and:
    1. Symptomatic patient of more serious intrathoracic injury or
    2. XRay with suspicious findings
      1. Hemothorax or large Pneumothorax
      2. Wide Mediastinum (>8cm)
      3. Multiple Rib Fractures or Flail Chest
      4. Fractured Sternum or Fracture of ribs 1 or 2
    3. Other possible indications for Chest CT and nondiagnostic Chest XRay
      1. Definitive Rib Fracture on imaging would alter management
      2. Rib Fracture is a clinical diagnosis
        Chest CT is not recommended solely for definitive Rib Fracture diagnosis
4. Minimal Trauma with normal Vital Signs, exam and adequate pain control
  1. Chest XRay is optional
Chest XRay (preferred first line test in most cases)
1. Rib Fracture
  1. Test Sensitivity for Rib Fracture: 33-50% (compared with CT)
    1. However, Rib Fractures not seen on Chest XRay are typically not Clinically Significant
  2. Turn XRay on its side (use software rotation)
    1. Follow arch lines of both anterior and posterior aspects of the ribs
    2. Fracture lines are more evident in this view
2. Pneumothorax
  1. Especially with Rib Fractures at 4-9
  2. Consider expiratory Chest XRay
3. Hemothorax
4. Pulmonary Contusion
5. Widened mediastinum
Rib XRay (Rib Detail Films)
1. Disadvantages
  1. Doubles radiation exposure compared with standard Chest XRay
  2. Adds little to evaluation in most cases beyond standard two view Chest XRay
    1. Rib films do not increase Test Sensitivity over Chest XRay when read by radiologists
    2. However, non-radiologist clinicians (e.g. EM) may find rib films useful in some cases
  3. Rib Fractures are a clinical diagnosis
    1. Rib films add nothing to a good history and exam for Rib Fracture
  4. More accurate modalities are preferred if definitive diagnosis required (rib Ultrasound, CT Chest)
2. Indications
  1. Consider in minor Trauma where Chest XRay is non-diagnostic
    1. If definitive diagnosis of Rib Fracture will alter management
  2. Consider in suspected Rib Fracture at ribs 1-3 and 9-12
    1. Cases in which confirmed Rib Fracture would prompt advanced imaging
3. References
  1. Sadhna (1995) Emerg Radiol 2(5): 264-6 [PubMed]
CT Chest
1. Indications
  1. Gold standard in Chest Trauma
    1. But not recommended for diagnosis of Rib Fracture alone, which should be made clinically
  2. Indicated for high risk injury as listed above under red flags
  3. Consider in elderly with suspected multiple Rib Fractures (high mortality risk)
    1. Non-contrast CT Chest is sufficient in the evaluation of Rib Fractures and non-hemorrhagic related complications
2. Defines high risk injuries (e.g. vascular injuries)
  1. Suspected Thoracic vascular injuries are the primary indication for Chest CT in Trauma
  2. Also defines Rib Fractures as well as Lung Contusion, Pneumonia, Pneumothorax, and Hemothorax
3. CT Angiography indications (suspected vascular injury, especially aorta)
  1. Fracture of ribs 1 or 2
  2. Neurovascular compromise in upper extremities (e.g. decreased pulses, neurologic deficit)
  3. Wide Mediastinum (>8 cm)
  4. Left Pleural Effusion
  5. Tracheal deviation to right
  6. Apical cap
  7. Left main stem Bronchus decompression
Rib Ultrasound
1. Indications
  1. Emerging as viable modality for bedside Rib Fracture evaluation
2. Disadvantages
  1. Time consuming for clinician and painful for patient
  2. Certain ribs may be more difficult to image
3. Technique
  1. Use high frequency linear probe along the bony contour of the rib
  2. Fracture should appear as a break in the hyperechoic line at the bony surface
4. References
  1. Turk (2010) Emerg Radiol 17(6):473-7 [PubMed]

Imaging
Other studies

FAST Exam
1. Evaluate for intra-abdominal Hemorrhage (hepatorenal margin, splenorenal margin), esp. for lower Rib Fractures
2. Evaluate for Pneumothorax and Pleural Effusion (possible Hemothorax)
CT Abdomen
1. Indicated for Rib Fracture at 10-12 and abdominal exam suggestive of injury
2. Evaluate for Liver Laceration and Splenic Rupture

Management

Trauma surgeon consult indications
1. High risk, high energy injury (see red flags above)
2. Surgical stabilization of Rib Fractures is typically only indicated in Flail Chest
  1. However, three or more contigious Rib Fractures may benefit from surgical stabilization
  2. Pieracci (2020) J Trauma Acute Care Surg 88(2): 249-57 [PubMed]
Pain management to decrease Splinting and improve ventilation (single most important intervention)
1. NSAIDs
2. Opioid Analgesics
3. Lidocaine Patch
4. Intercostal block
5. Epidural Anesthesia (hospitalized patients)
Incentive spirometer
1. Theoretically should reduce Atelectasis and Pneumonia risk
2. No evidence of benefit, but unlikely to cause harm, and marker of adequate pain control
3. Use 10 times every 1-2 hours while awake for at least 1 week or until pain is minimal
Discharge indications
1. Young patient under age 65 years and
2. Two or less Rib Fractures and
3. No lung parenchymal injury and no Abdominal Injury and
4. No comorbidity and
5. Adequate pain control on Oral Analgesics
Follow-up
1. Educate patients on warning signs
  1. Delayed Hemothorax occurs in 4-7% of cases (rare without multiple or displaced Rib Fractures)
  2. Delayed Pneumothorax occurs in 2-5% of cases
  3. Pneumonia occurs in up to 31% of elderly with Rib Fractures
  4. Non-union can occur
2. Immediate re-evaluation
  1. Shortness of Breath
  2. Increasing pain
  3. Productive cough
  4. Fever
3. Not improving
  1. Follow-up in 48 to 72 hours
4. Routine re-evaluation
  1. Follow-up in 1-2 weeks for pain management
  2. Expect 6 weeks for complete healing
5. Return to Play guidelines
  1. Patient should be able to perform activity for 4-8 weeks without pain
  2. May use rib protectors on gradual return to play
Hospitalization indications
1. Older patients
  1. Especially consider admission if debilitated or serious comorbidity (COPD, CAD, liver or renal disease)
  2. Higher risk of Atelectasis and secondary Pneumonia (up to 31% secondary Pneumonia Incidence in elderly)
  3. Stawicki (2004) J Am Geriatr Soc 52: 805-8 [PubMed]
2. Rib Fractures and comorbidity (e.g. underlying heart or lung disease)
3. Intractable pain requiring Parenteral Opioids
4. Multiple Rib Fractures
  1. Number of Rib Fractures does not correlate well with complication rate
    1. Better predictors: Pain control, comorbidity, functional status, injury mechanism, Lung Contusion
    2. However in most cases, 4-5 Rib Fractures are likely to be admitted for pain control
  2. Three or more Rib Fractures in patients over 65 years
  3. Five or more Rib Fractures at any age
  4. Flail Chest
5. Intrathoracic or extrathoracic secondary injury
  1. High risk injuries such as first 3 Rib Fractures, Sternal Fracture or Scapular Fracture (see red flags above)
  2. Lung Contusion or other parenchymal injury
  3. Liver or Spleen injury
6. Pediatric Rib Fractures (especially displaced or multiple)
  1. Associated with high energy injury and high risk of intrathoracic injury
  2. Consider admission to Pediatric Trauma service
  3. Consider Nonaccidental Trauma (especially multiple, under 18 months old and posteromedial Rib Fractures)

Prognosis
Mortality Risk Factors

Severe mechanism of injury (with secondary intrathoracic injury)
Age 65 or older
1. Twice mortality of younger patients
2. Mortality 10% for 1 to 2 Rib Fractures
3. Mortality 20% for 2 to 3 Rib Fractures
4. Mortality 30% for >6 Rib Fractures
5. Bulger (2000) J Trauma 48(6): 1040-6 [PubMed]
More than 5 Fractured ribs
Age 46-65 years old

Complications

Pain induced Splinting complications
1. Increased risk with underlying comorbidity (e.g. COPD, CAD, liver or Kidney disease or Dementia)
2. Atelectasis (due to Splinting)
3. Pneumonia
4. Acute Respiratory Distress Syndrome
Rib Fracture at ribs 1 to 3
1. Neurovascular injury (e.g. subclavian vessels, Brachial Plexus)
2. High energy injury (ribs 1-3 Fractured or Sternal Fracture, Scapula Fracture)
  1. Lung Contusion
  2. Cardiac Contusion
  3. High mortality risk
3. First Rib Fracture may form callus on healing
  1. Risk of Thoracic Outlet Syndrome
Rib Fracture at ribs 4 to 9 (most commonly injured ribs)
Rib Fracture at ribs 10 to 12
High energy injury (Rib Fracture 1-3, Sternum Fracture, Scapula Fracture)
1. Lung Contusion
2. Cardiac Contusion
3. High mortality risk

References

Dreis (2020) Crit Dec Emerg Med 34(7):3-21
Bhavnagri (2009) Clev Clin J Med 76(5):309-14
Jaber (2013) Crit Dec Emerg Med 27(3): 12-17
Raja and Mason in Swadron (2022) EM:Rap 22(1): 12
Spangler and Inaba in Herbert (2017) EM:Rap 17(1): 12-13
Livingston (2008) J Trauma 64(4): 905-11 [PubMed]