Rib fracture

Background

Multiple Right sided rib fractures

• Diagnostic goal: detect commonly associated conditions: hemopneumothorax, pulmonary contusion, intra-abdominal injury, major vascular injury
• Pediatrics: <2 years old with >2 rib fractures = 50% mortality
  • Ribs more flexible in children, so fractures require extreme force
• Elderly: double the mortality of younger patients

Diagnosis

• Chest x-ray
  • 1st & 2nd rib fractures associated with severe chest trauma and underlying injury
  • 9th, 10th, 11th rib fractures associated with intra-abdominal injury

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Management

• Dilaudid PCA upon decision to admit
• Incentive spirometry
• EzPAP® positive airway pressure system
• Early NSAIDs for multiple rib fractures to reduce pna
  • Ibuprofen 800 mg IV q6hrs
  • OR ketorolac 15-30 mg IV q6 hrs
  • Limit IV NSAIDs to maximum of 5 days
• Transition to PO narcotics and NSAIDs whenever possible
• Consider addition of:
  • Continuous epidural bupivacaine infusion if failure of PCA/NSAIDs
  • Diazepam 10 mg IV/PO q4-6 hrs if respiratory rate adequate

Disposition

• Strongly consider admission for more than one rib fracture in elderly patient or patient with preexisting pulmonary disease
  • Difficult for these patients to cough / clear secretions
• If discharged:
  • Teach how to splint and cough
  • Be liberal with pain medicine
  • Encourage incentive spirometer or tell to blow up balloons
  • Discourage rib belts or straps

See Also

• Fracture (Main)

Source

• Tintinanlli