• The most common mechanism associated with rib fracture is blunt trauma (1).
• Non traumatic causes secondary to cancer and osteoporosis will not be reviewed here.
• Diagnosis is frequently made on Chest Xray, but CT may be considered if suspicious for underlying injuries or in elderly populations.
  • NEXUS CT Chest rule can provide some guidance on when to image in trauma cases.
  • Ultrasound/PoCUS can be an alternative to Chest Xray if the user is proficient in its use.
  • CT remains the gold standard.
• Rib fractures and associated injuries often carry a high mortality. In adults a mortality of up to 10% has been shown and this increases up to 20% in patient populations >65 yo (2,3).
• 1st and 2nd rib fractures may be associated with great vessel injury, whereas fractures to ribs 9-12 can cause splenic, liver or kidney laceration (4).
• Pulmonary complications including pneumothorax, hemothorax, pulmonary contusion, pneumonia and atelectasis are common and may be seen in 16-52% of blunt trauma cases with rib fracture (4).

• The majority of isolated/simple rib fractures <3, non flail segment, no associated injuries will respond to conservative management (1,3).
• Pain can compound an underlying pulmonary contusion leading a patient into Acute Respiratory Distress Syndrome (5).

Pitfalls

• Not recognizing associated injuries either pulmonary (listed above), abdominal solid organ or thoracic great vessels.
• Under-treating pain may lead to respiratory deterioration.
• If there is a high index of suspicion order a CT chest for more definitive characterization of injuries.

Respiratory

• Incentive spirometer (1,5).
• Pulmonary hygiene including chest physiotherapy, pulmonary toilet, cough and deep breath, and early mobilization lack data and evidence but have been included in the most recent Western Trauma Association guidelines (2).

Pain Control (Similar to WHO analgesic ladder)

• Acetaminophen and Ibuprofen (2,5).
• Opiates, start with oral and step up to IV if needed, used in conjunction with either acetaminophen or ibuprofen (3,5).
• Other adjuncts to consider include gabapentin and muscle relaxants although these have limited evidence.
• Some studies have shown benefit of epidural delivered opiates in pain control (3,5). This is more applicable in an inpatient setting.

Regional Anesthesia

• Newer opiate sparing techniques involving regional anesthesia have shown promise but unfortunately there is limited data to support their widespread use at this time (3,5).
  • Techniques include the paravertebral block, intercostal block, serratus anterior block, or the erector spinae block.

Respiratory

• Hypoxemia O2Sat <92% on RA (requiring O2) (3).
• Incentive spirometry <1,000 cc or <15 cc/kg, or a vital capacity of less than 1.4 or 55% of predicted (3).

Age

• Age cutoffs are arbitrary but some institutions recommend admission and observation for >2 rib fractures in patents >65 yo (2).
• Elderly populations are at higher risk for developing complications including pneumonia (5).

Severity

• Flail chest, associated hemothorax, pneumothorax should be admitted and reviewed with trauma service.
• Severe pulmonary contusions will likely exhibit respiratory distress/comprise (as above) and should be admitted.
• Patients with >3 rib fractures, displaced fractures or underlying lung conditions can be considered for admission.

A variety of scoring systems have been developed:

• If there are severe injuries requiring respiratory support patient may benefit from intubation/ventilation and transfer to ICU/trauma facility.
• Primary transport considerations include ventilation and pain control.

• Uncontrolled Pain.

• Adequate pain control.
• Patient able to cough and take deep breath (3).
• No significant underlying injury (see above).
• O2 sat >92% on RA. Ability to perform incentive spirometry >1,000 cc or >15 cc/kg, and a vital capacity of greater than 1.4 or 55% of predicted (3).

• There is limited evidence for follow up chest X-ray in isolated rib fractures, although may consider in higher risk patients.

• Patients may benefit from outpatient follow-up of pain control.

1. NEXUS Chest CT Decision Instrument for CT Imaging – www.mdcalc.com

   
   

2. Trouble with rib fractures? Learn chest wall blocks (serratus!) with @highland herring. #FOAMed -UltrasoundPodcast.com

   
   

3. Erector Spinae Plane Block – BCpocus.ca

   
   

4. Rib Fractures – JAMA Network Patient Page

   
   

1. Serfin et al. Rib Fractures: Resources. The American Association for the Surgery of Trauma webpage 2018.

   
   

2. Brasel KJ, Moore EE, Albrecht RA, deMoya M, Schreiber M, Karmy-Jones R, Rowell S, Namias N, Cohen M, Shatz DV, Biffl WL. Western Trauma Association Critical Decisions in Trauma: Management of rib fractures. J Trauma Acute Care Surg. 2017 Jan;82(1):200-203. doi: 10.1097/TA.0000000000001301.

   
   

3. Galvagno et al. Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. Journal of Trauma and Acute Care Surgery: November 2016 – Volume 81 – Issue 5 – p 936–951.

   
   

4. Sirmali et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003 Jul;24(1):133-8.

   
   

5. May et al. Rib fracture management. BJA Education. 2016 Jan;16(1):26-32.