Rib Fracture

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Background

Simple rib fractures are the most common injury sustained following blunt chest trauma, accounting for more than half of thoracic injuries from nonpenetrating trauma. Approximately 10% of all patients admitted after blunt chest trauma have one or more rib fractures. These fractures are rarely life-threatening in themselves but can be an external marker of more severe visceral injury inside the abdomen and the chest.

The image below depicts aortic injury, closely associated with a widening of greater than 8 cm measured at the widest points of the mediastinum.


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Aortic injury is closely associated with a widening of greater than 8 cm measured at the widest points of the mediastinum on an upright anteroposterio....

The most common mechanism of injury for rib fractures in elderly persons is a fall from height or from standing. In adults, motor vehicle accident (MVA) is the most common mechanism. Youths sustain rib fractures most often secondary to recreational and athletic activities, as well as by nonaccidental trauma.

Rib fractures may also be pathologic. Cancers that metastasize to bone (eg, prostate, breast, renal) frequently become apparent in a rib. Ribs are relatively thin compared with major long bones and are more likely to fracture when invaded by a metastatic lesion.

In a study of Japanese patients with rheumatoid arthritis who were followed over a mean duration of 5.2 years, 13.5% reported incident fractures, with rib fractures being the most common fractures in men and vertebral fractures being the most common fractures in women, followed by rib fractures.[1]

Pathophysiology

The chest wall protects underlying sensitive structures by surrounding internal organs with hard osseous structures including the ribs, clavicles, sternum, and scapulae. An intact chest wall is necessary for normal respiration.

Rib fractures may compromise ventilation by a variety of mechanisms. Pain from rib fractures can cause respiratory splinting, resulting in atelectasis and pneumonia. Multiple contiguous rib fractures (ie, flail chest) interfere with normal costovertebral and diaphragmatic muscle excursion, potentially causing ventilatory insufficiency. Fragments of fractured ribs can also act as penetrating objects leading to the formation of a hemothorax or a pneumothorax. Ribs commonly fracture at the point of impact or at the posterior angle (structurally their weakest area). Ribs four through nine (4-9) are the most commonly injured.

The thinnest and weakest portion of the first rib is at the groove for the subclavian artery.[2] The mechanism of first-rib injury in motor vehicle accidents seems to be a violent contraction of the scalene muscles brought on by the sudden forward movement of the head and neck.[3]

A single blow may cause rib fractures in multiple places. Traumatic fractures most often occur at the site of impact or the posterolateral bend, where the rib is weakest.

Due to the greater pliability of children's ribs, greater force is required to produce a fracture.

Epidemiology

Frequency

United States

The incidence of rib fractures is dramatically underreported. More than 2 million blunt mechanisms of injury occur annually just as motor vehicle collisions, with reported incidence of chest injury between 67 and 70% of those.[4]

International

The prevalence of rib fractures is linked to the prevalence of the underlying cause of the trauma. Rib fractures are more common in countries with higher incidence of MVAs.

Mortality/Morbidity

Rib fractures are not usually dangerous in and of themselves. Patients may develop pneumonia from splinting. Morbidity correlates with the degree of injury to underlying structures.

In one study of patients with rib fractures, the mortality rate reached 12%; of these, 94% had associated injuries and 32% had a hemothorax or a pneumothorax.[5] More than half of all patients required either operative or ICU management. Average blood loss per fractured rib is reportedly 100-150 mL.

In one retrospective study of 99 elderly patients, 16% of patients (95% confidence interval [CI], 9.5-24.9%) developed adverse events, including 2 deaths.[6] Adverse events were defined as acute respiratory distress syndrome (ARDS), pneumonia, unanticipated intubation, transfer to ICU for hypoxemia, or death. Risk factors associated with these adverse events were age ≥85 years, initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 or more unilateral rib fractures, or pulmonary contusion. These risk factors predicted adverse events with 100% sensitivity (95% CI, 79.4-100%), and 38.6% specificity (95% CI, 28.1-49.9%), and they may identify variables that might aid in identifying patients at high risk for serious adverse events if validated in a larger prospective study.

Rib fractures are the most common injury in elderly blunt chest trauma patients, and each additional rib fracture increases the odds of dying by 19% and of developing pneumonia by 27%.[7, 8]

Position of the fractured rib in the thorax helps identify potential injury to specific underlying organs. Fracture of the lower ribs usually is associated with injury to abdominal organs rather than to lung parenchyma. Fracture of the left lower ribs is associated with splenic injuries, and fracture of the right lower ribs is associated with liver injuries. Fracture of the floating ribs (ribs 11, 12) is often associated with renal injuries.

First rib fractures have often been described as having a high association with serious or lethal spinal or vascular injuries.[9] They are rarest of all rib fractures[3] and were once thought to be a harbinger of severe trauma,[10] since the first rib is very well protected by the shoulder, lower neck musculature, and clavicle.

First rib fractures were thought to require a much higher impact force to fracture than other ribs, but that theory is now in question. Until further studies are done, fractures of the first rib should raise suspicion of significant chest trauma. The presence of a first rib injury requires a multidisciplinary approach. CT of the spine and chest allows for an early diagnosis. Appropriate treatment and observation in the intensive care unit may prevent further morbidity and/or mortality.[9]

While first rib fractures have a high association with spinal fractures and are associated with multisystem injuries, the occurrence of first rib fractures is not always associated with increased morbidity and mortality.[9] Mortality rates as high as 36% have been previously reported with fractures of the first rib, which are associated ith injury to the lung, ascending aorta, subclavian artery, and brachial plexus. Other complications associated with first rib fractures include delayed subclavian vessel thrombosis, aortic aneurysm, tracheobronchial fistula, thoracic outlet syndrome,[11] and Horner's syndrome.[12]

The association of lower rib fractures with pelvic fractures has been associated with a higher incidence of solid organ injury.[13]

Age

Because children have more elastic ribs, they are less likely than adults to sustain fractures following blunt chest trauma. Elderly individuals are more likely to have associated injuries and complications.

Children present more frequently with trauma to the underlying chest and abdominal organs without the associated rib fractures commonly seen in adults. Classically, this made rib fractures in children an ominous sign of potential high-force injury.

Bruising near the fracture site is uncommon with pediatric rib fractures, seen in only 9.1% of pediatric rib fractures in one study.[14]

Consider child abuse in children who lack a significant mechanism for multiple rib fractures or have fractures in different stages of healing. Children younger than 2 years with rib fractures have a prevalence of child abuse as high as 83%.

Older persons are more prone to rib fractures than younger adults[15] and, therefore, the pulmonary sequelae such as atelectasis, pneumonia, and respiratory arrest. The presence of cardiopulmonary disease also significantly increases morbidity and mortality rates in patients older than 65 years. The clinical benefits of a rib scoring system has been tested at one site for hospitalized older adults.[16]

History

Physical

Causes

Laboratory Studies

Imaging Studies

Chest radiographs

Rib radiographs

Bedside ultrasonography

Chest CT scan

Angiography

Bone Scan

MRI

Prehospital Care

Prehospital care should focus on airway maintenance and supplemental oxygen.

Emergency Department Care

Goal of initial ED care is stabilization of the trauma patient and multisystem trauma evaluation.

Consultations

Medication Summary

Pain control remains the mainstay of treatment, usually with nonsteroidal anti-inflammatory or oral narcotic agents.

Ibuprofen (Ibuprin, Advil, Motrin)

Clinical Context:  First-line drug of choice for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which, in turn, decreases prostaglandin synthesis.

Ketoprofen (Oruvail, Orudis, Actron)

Clinical Context:  For relief of mild to moderately severe pain and inflammation.

Administer small dosages initially to patients with lower body weights, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and observe closely.

Naproxen (Anaprox, Naprelan, Naprosyn)

Clinical Context:  Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Class Summary

These agents are used most commonly for the relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually the first-line drug of choice for initial therapy. Other options include fenoprofen, flurbiprofen, ketoprofen, indomethacin, and piroxicam.

Acetaminophen (Tylenol, Panadol, Paracetamol)

Clinical Context:  DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Effective in relieving mild to moderate acute pain; however, has no peripheral anti-inflammatory effects. May be preferred in elderly patients because of fewer GI and renal side effects.

Acetaminophen and codeine (Tylenol #2, Tylenol #3, Tylenol #4)

Clinical Context:  Combines analgesic effects of a centrally acting opium-derived alkaloid (codeine) and a peripherally acting nonopioid analgesic (acetaminophen). Indicated for treatment of mild to moderate pain.

Hydrocodone and acetaminophen (Vicodin)

Clinical Context:  Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Clinical Context:  Drug combination indicated for the relief of moderate to severe pain. DOC for aspirin-hypersensitive patients.

Oxycodone and aspirin (Percodan)

Clinical Context:  Drug combination indicated for relief of moderately severe to severe pain.

Hydrocodone and ibuprofen (Vicoprofen)

Clinical Context:  Drug combination indicated for the relief of moderate to severe pain.

Morphine

Clinical Context:  Used to achieve a desired anxiolytic and analgesic effect because easily titrated to desired level of pain control or sedation. Reversed by naloxone.

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Further Inpatient Care

Further Outpatient Care

Transfer

Deterrence/Prevention

No clear data indicate how to decrease the number of rib fractures associated with car crashes as the restraint systems all exert force on the rib cage.

Complications

Complications of rib fracture may include the following:

First rib fractures have often been associated with serious head injury, cervical spine injury, delayed subclavian vessel thrombosis, aortic aneurysm, tracheobronchial fistula, thoracic outlet syndrome, and Horner syndrome.[3]

A small percentage of rib fractures do not heal even though a fibrous capsule may envelope the fracture. A nonunion may present months to years after injury and can cause discomfort with respiration due to movement of the fracture site. Some patients find the respiratory restriction due to pain quite disabling.

Prognosis

Author

Sarah L Melendez, MD, Clinical Assistant Instructor, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center and Kings County Hospital Center

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, FACEP, Associate Professor of Emergency Medicine, Residency Program Director, Vice-Chair for Education, Department of Emergency Medicine, University of Kentucky-Chandler Medical Center

Disclosure: Nothing to disclose.

Specialty Editors

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD, Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Disclosure: WebMD Salary Employment

Additional Contributors

Laurie K Mahoney, MD, FAAEM Attending Physician, Department of Emergency Medicine, Long Island College Hospital, Brooklyn

Laurie K Mahoney, MD, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, and American College of Emergency Physicians

Disclosure: Nothing to disclose.

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Aortic injury is closely associated with a widening of greater than 8 cm measured at the widest points of the mediastinum on an upright anteroposterior chest radiograph.

Aortic injury is closely associated with a widening of greater than 8 cm measured at the widest points of the mediastinum on an upright anteroposterior chest radiograph.

Normal sonogram of the anterior chest wall using a 7.5-MHz linear transducer. The double arrows show the short-axis view of a rib, with its hyperechoic margin and posterior acoustic shadowing. P denotes the "pleural line" that is also hyperechoic and that should not be mistaken as the rib margin.

Long-axis view of a fractured left third rib of a patient using a 12-MHz linear transducer. The disruption of the hyperechoic cortical alignment is shown by the arrows.

Aortic injury is closely associated with a widening of greater than 8 cm measured at the widest points of the mediastinum on an upright anteroposterior chest radiograph.

Normal sonogram of the anterior chest wall using a 7.5-MHz linear transducer. The double arrows show the short-axis view of a rib, with its hyperechoic margin and posterior acoustic shadowing. P denotes the "pleural line" that is also hyperechoic and that should not be mistaken as the rib margin.

Long-axis view of a fractured left third rib of a patient using a 12-MHz linear transducer. The disruption of the hyperechoic cortical alignment is shown by the arrows.