EM@3AM: Rib Fractures

Author: Seth Cohen, MD (@secohen11, EM Resident Physician, UTSW, Dallas, TX); Joshua Kern, MD (EM Attending Physician, UTSW, Dallas, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


An 82-year-old female with no significant past medical history presents to the ED after falling down a flight of stairs. Patient reports tripping over the rug at the top of the stairs and falling onto her chest. She denies hitting her head, blood thinner use, and loss of consciousness. She endorses right sided chest pain that began immediately after falling but denies any shortness of breath.

Vital signs: HR 90 bpm, BP 148/100, RR of 20, T of 98.8F, and SPO2 of 97%. Examination shows a frail elderly female, with ecchymosis over the right chest wall. Tenderness to palpation is pinpoint over the 5th and 6th ribs on the right. Breath sounds are equal bilaterally.

What is the most likely diagnosis?


Answer: Rib fractures

 

Background:

  • Adult patients with rib fractures
    • Mortality rate of 10%
    • Complication rate of 13%
      • 48% of complications being pulmonary in cause1, including pneumonia, acute respiratory distress syndrome, pneumothorax, aspiration pneumonia, and empyema
    • Elderly patients
      • Highest risk of rib fractures due to osteoporosis
      • Each rib fracture increases the risk of pneumonia by 27% and the mortality by 20%2
    • Rib fractures occur in approximately 9-10% of trauma patients3

 

Pathophysiology:

  • Occur most often following blunt thoracic trauma4
  • May also result from severe coughing, swinging golf clubs, throwing objects, and nonaccidental trauma5
  • Ribs 4-10 are most prone to fracture with blunt force trauma as ribs 1-3 are relatively protected by the scapula and clavicle, and ribs 10-12 are relatively mobile
  • Most fractures typically occur at the site of impact or at the posterolateral bend where the rib is the weakest4
  • Consider non accidental trauma with pediatric rib fractures as their ribs are more flexible and ultimately require more force to be fractured

 

Clinical Presentation:

  • Localized pain to the fractured ribs exacerbated with deep breaths
  • History taking typically involves a blunt trauma to the ribs
  • Examination findings include point tenderness over the fractured ribs
  • May have bony crepitus (an auscultated click heard with a stethoscope over fracture site) and overlying ecchymosis

 

Complications:

  • Assess for diminished breath sounds caused by splinting (taking short, shallow breaths) secondary to pain or the presence of a pneumo/hemothorax
    • Long term complications of splinting include atelectasis and pneumonia
  • Fractures of ribs 9-12 may be associated with intraabdominal injury
  • Fractures of right lower ribs are associated with hepatic injuries while fractures of the left lower ribs are associated with splenic injury. Fractures of posterior ribs are associated with renal injury
  • Fractures of ribs 1-3 may be associated with mediastinal injury, particularly of the aorta6
  • Flail chest occurs when multiple adjacent ribs are each fractured in two places
    • This creates a floating segment which exhibits paradoxical motion with breathing and is often associated with pulmonary injury

 

Evaluation:

  • Posterior-anterior and lateral chest radiographs are commonly used but have overall poor sensitivity (With CT used as standard, sensitivity 54.7%, specificity of 96.8%)7
  • Anterior-posterior chest radiograph is frequently used in trauma due to hemodynamic instability or spinal immobilization
  • Rib dedicated film’s sensitivity is higher than chest radiographs as they use a bone exposure and include oblique chest wall views (With CT used as standard, sensitivity 82%)8
    • Rarely utilized
  • If an injury that would require a change in management is suspected, CT scan of the chest should be utilized9
    • Median number of additional fractures identified by CT compared to chest XR in patients with rib fractures is 310
    • 5% of patients with rib fractures had a change in clinical management based upon a CT compared to CXR10
      • Change in management includes SICU admission, pain catheter placements, epidural placements, surgical stabilization
      • However, no improvement in pulmonary morbidity (acute respiratory failure, mechanical ventilation duration, pneumonia, ARDS, tracheostomy need), hospital length of stay, SICU length of stay, or mortality in patients with a clinically meaningful increase in the number of rib fractures10
    • Due to each rib fracture increasing the risk of pneumonia and mortality in elderly patients (see background section)2, consider using CT scans in the elderly

  • Ultrasound has limited evidence in assessing rib fractures but small studies have shown higher sensitivity (80-98.3%)11, 12 and specificity (100%)11 compared to chest radiographs
    • Average duration of ultrasound use was 12 +/- 3 minutes whereas the duration of radiography was 27 +/- 6 minutes12
    • Look for discontinuity of cortical alignment and an acoustic linear edge shadow to diagnose a rib fracture12
    • Ultrasound poorly evaluates upper ribs under the scapula and first rib under the clavicle. Obesity and large breasts are also factors that are associated with reduced ultrasound quality12
    • Also an effective tool in assessing for rib fracture complications such as pneumothorax13

 

Management:

  • Analgesics to provide adequate pain relief so complications from splinting are avoided
  • NSAIDs are primary analgesia but intercostal nerve blocks are becoming more utilized
  • Nerve blocks:
    • Types include intercostal nerve block, erector spinae plane block, serratus anterior plane block (see the FOAMed section below for links on how to perform a regional nerve block)
    • Regional analgesia as opposed to NSAIDs is associated with lower mortality, and incidence of pneumonia14
    • Patients who were given regional analgesia additionally required fewer opiates than those who were given systemic therapy14
  • Encourage incentive spirometer use to prevent atelectasis

 

Disposition:

  • PIC score can help guide care
    • Should be used to help monitor improvement, not to guide disposition
    • Unanticipated escalation of care for ARDS was reduced from 3% to 0.37% by utilizing PIC scores15
      • ARDS was predicted by a fall in the PIC score of 3 or more points over an 8 hour shift15
    • Composite score of 0-10 (10 being goal score)
    • Pain is scored subjectively on a 0-10 scale by the patient
      • 0-4 gets 3 points
      • 5-7 gets 2 points
      • 8-10 gets 1 point
    • Inspiratory capacity is scored on a 1-4 scale.
      • Above goal volume = 4
      • At goal volume = 3
      • Below goal volume = 2
      • Unable to perform = 1
    • Cough is subjectively assessed
      • Strong cough = 3
      • Weak cough = 2
      • No cough = 1
  •  Consider admission to ICU for16:
    • Severe rib fractures (greater than 5 ribs, multiple displaced fractures, flail chest)
    • Signs of significant respiratory compromise including hypoxia or incentive spirometer less than 60% of predicted
    • Risk of respiratory decompensation
    • Significant associated injury identified requiring ICU care
  • Consider admission inpatient admission for16:
    • 65 years or older
    • 3-5 uncomplicated rib fractures
    • Tachypnea despite adequate pain control
    • Incentive spirometer less than 75% of predicted
    • Intractable pain
  • Surgery consult recommended for:
    • Chest wall deformity
    • Flail chest
  • Consider discharge for:
    • Patients with none of the above criteria

 

Key Points:

  • Rib fractures can have serious complications including hemo/pneumothorax, aortic injury, and splenic/liver lacerations
  • Adults, especially elderly patients, have a high risk of complications with rib fractures
  • Evaluate with a chest x-ray. Follow up with a CT if there is suspicion for any chest/abdomen injuries that would require a change in management
  • Reinforce the importance of an incentive spirometer and appropriate analgesia

Further FOAMed Reading:

 

References:

  1. Flagel B, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005. 138.
  2. Baiu I, Spain D. Rib Fractures. JAMA. 2019. 321(18). DOI: 10.1001/jama.2019.2313
  3. Ziegler D, Agarwal N. The morbidity and mortality of rib fractures. Journal of Trauma. 1994. 37.
  4. Love J, Symes S. Understanding rib fracture patterns: Incomplete and buckle fractures. Journal of Forensic Science. 2004. 49(6). PMID: 15568684.
  5. Sinha A, Kaeding C, Wadley G. Upper extremity stress fractures in athletes: clinical features of 44 cases. Clinical Journal of Sport Medicine. 1999. 9(4). PMID 10593213.
  6. Murphy C, Raja A, Baumann B, et al. Rib fracture diagnosis in the Panscan Era. Annals of Emergency Medicine. 2017. 70(6). PMID: 28559032.
  7. Lo, R, Bennett, S, Macmahon, H. Sensitivity and Specificity of Chest Radiography and Rib Series for Detection of Rib Fractures.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 – December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13028734.html.
  8. Hoffstetter P, Dornia C, Schafer S, Wagner M, Dendl L, Stroszcynski C, Schreyer A. Diagnostic significance of rib series in minor thorax trauma compared to plain chest film and computed tomography. 2014. 8(10). PMID: 25152770.
  9. Kea B, et al. What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma? American Journal of Emergency Medicine. 2013. 31(8). PMID: 23796979.
  10. Chapman B et al. Clinical utility of chest computed tomography in patients with rib fractures CT chest and rib fractures. 2016. 5(4). PMID: 28144607.
  11. Rainer T, Griffith J, Lam E, Lam P. Comparison of thoracic ultrasound, clinical acumen, and radiography in patients with minor chest injury. The Journal of Trauma. 2004. 56(6). doi: 10.1097/01.TA.0000075800.65485.48.
  12. Pishbin E, Ahmadi K, Foogardi M, Salehi M, Toosi F, Movaghar V. Comparison of ultrasonography and radiography in diagnosis of rib fractures. Chinese Journal of Traumatology. 2017. 20(4). PMID: 28687342.
  13. Chan S. Emergency bedside ultrasound for the diagnosis of rib fractures. American Journal of Emergency Medicine. 2009. 27(5). PMID: 19497469.
  14. Uhlich R, Kerby J, Bosarge P. Use of continuous intercostal nerve blockade is associated with improved outcomes in patients with multiple rib fractures. 2021. 6(1). doi:1136/tsaco-2020-000600.
  15. Terry S, Shoff K, Sharrah M. Improving Blunt Chest wall Injury Outcomes: Introducing the PIC Score. Journal of Trauma Nursing. 2021. 28(6). doi: 10.1097/JTN.0000000000000618.
  16. Brasel K, et al. Western trauma association critical decisions in trauma: Management of rib fractures. Journal of Trauma Acute Care Surgery. 2017. 82(1). PMID: 27779590.

 

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