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)

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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