Recommendations

Key Recommendations

Rib fractures are an indicator of severe trauma. Assessment of a patient suspected to have a rib fracture should therefore include identification of the fracture itself and any concurrent injuries. The proportion of patients with concomitant injuries can be as high as 90%.[31] The presence of multiple rib fractures correlates with an increased incidence of solid organ injury (about 35%).[26]​ Fracture of a first or second rib should alert the physician to the possibility of vascular or neurologic injury as greater force is required to fracture these two ribs, which are intimately associated with the subclavian artery and the brachial plexus.[23][24][25]

History and exam

Rib fractures are most commonly a result of motor vehicle collisions (MVCs), falls, blunt trauma, assaults, and industrial incidents.[6][8][30] Other risk factors include age >65 years, osteoporosis, and cardiopulmonary resuscitation.[4][7][13][28] The patient or the emergency medical service personnel can provide important information regarding the likely etiology, such as blunt trauma in a car accident. Significant intrusion of the steering column can apply dramatic force to the thoracic cage.

Pain and dyspnea are common. Chest wall pain reduces ventilation by impaired inspiratory effort. Impaired oxygenation can also be indicative of underlying pneumothorax, hemothorax, or pulmonary contusion. Paradoxical chest wall motion with inspiration or expiration is a sign of a flail chest. A flail chest results when multiple ipsilateral ribs are fractured in two or more places resulting in an unstable segment of the chest wall. Flail chest is often accompanied by other injuries and carries an increased risk of life-threatening respiratory failure, pneumothorax, pulmonary contusion, and hemothorax, with an overall mortality of at least 5%.[32]

Other factors to consider:

  • Stress fractures occur in 2% to 12% of rowers as a result of cyclic loading to the rib cage.[22] It is also common in overhead repetitive athletic activities, such as baseball and golf.[21] Diagnosis is suggested by continued pain despite the absence of trauma.

  • Anyone with a known malignancy, particularly of lung, prostate, breast, liver, or gastrointestinal origin, could present with rib metastasis.

  • Primary bone tumors of the chest wall, including osteochondroma, enchondroma, plasmacytoma, chondrosarcoma, and osteosarcoma, are rare but can manifest as rib fractures. About 37% of these lesions are malignant.[16] Multiple myeloma can present with rib fractures and even with a flail chest.[17]

  • Any rib fracture in a child or infant should be assumed to be the result of nonaccidental trauma until shown otherwise. Among infants younger than 12 months presenting with rib fractures, as many as 82% sustained these injuries non-accidentally (i.e., through physical abuse).[2][3] Of all skeletal injuries, rib fractures have the highest likelihood of being the result of physical abuse.[14]

Investigations

  • Chest radiography is the first-line imaging modality in any patient presenting with known trauma.[33][34]​​ This not only helps detect the actual rib fracture, but pneumothorax, hemothorax, and aortic injury can also be rapidly assessed. However, conventional chest x-rays (CXR) can miss up to 50% of rib fractures.[35] In practice, a single rib fracture might be diagnosed clinically based on symptoms and a clear history of thoracic trauma, even if no fracture is identified on CXR; further imaging is only warranted if it has the potential to change patient management. It is not usually necessary to perform dedicated rib radiography, in addition to chest radiography, for the diagnosis of rib fractures in adults after minor trauma.[33][Figure caption and citation for the preceding image starts]: CXR showing right first rib fractureFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].CXR showing right first rib fracture[Figure caption and citation for the preceding image starts]: CXR showing multiple posterior left-sided rib fracturesFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].CXR showing multiple posterior left-sided rib fractures[Figure caption and citation for the preceding image starts]: Anteroposterior CXR multiple left-sided rib fractures with chest tube in placeFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].Anteroposterior CXR multiple left-sided rib fractures with chest tube in place

  • Computed tomography (CT) of the chest has greater sensitivity than CXR in detecting rib fractures as well as other injuries. A majority of patients who sustain major trauma and have evidence of chest injury on plain x-ray have an unsuspected injury identified on chest CT; up to one-third of these patients have their management significantly changed as a result of the chest CT.[36] CT imparts significant radiation exposure to the patient but should be considered if clinical features are suggestive of fracture and there is the potential for improved patient care if rib fracture(s) are detected. In minor trauma, however, the increased sensitivity of CT does not necessarily alter management or clinical outcomes of patients who do not have associated injuries.[33][Figure caption and citation for the preceding image starts]: CT scan showing large left-sided pneumothoraxFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].CT scan showing large left-sided pneumothorax[Figure caption and citation for the preceding image starts]: CXR depicting the same pneumothorax as shown on CTFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].CXR depicting the same pneumothorax as shown on CT[Figure caption and citation for the preceding image starts]: CT scan showing bilateral posterior rib fracturesFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].CT scan showing bilateral posterior rib fractures[Figure caption and citation for the preceding image starts]: CT showing right anterolateral rib fractureFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].CT showing right anterolateral rib fracture[Figure caption and citation for the preceding image starts]: CT showing left posterior segmental rib fractureFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].CT showing left posterior segmental rib fracture

  • Ultrasound has been evaluated for its usefulness in diagnosing rib fractures. It is marginally superior to chest radiography, but may be associated with patient discomfort. Ultrasound is more typically used as an adjunct, in some centers, to rapidly assess for pneumothorax and pleural fluid; diagnostic accuracy is operator-dependent.[33][37][38]

  • Routine use of angiography is not indicated in the absence of discrepant pulses, mediastinal widening on CXR, brachial plexus injury, or an expanding hematoma.[23] However, it may be used if there is a fracture of a first rib as traumatic injuries to the first rib are associated with a 3% risk of concomitant great-vessel injury.[23]

  • Typically, patients presenting after high-energy trauma should receive an immediate chest and pelvic radiograph to rule out life-threatening injury.[39] If the patient is stable, a CT scan of the head, cervical spine, chest, abdomen, and pelvis may be performed in adults to rule out other injury.[39]

  • A skeletal survey and a consultation with child protective services should be considered in all children with suspected physical abuse. Oblique views of the ribs are recommended in all cases where abuse is suspected.[40] Oblique views increase diagnostic accuracy for rib fractures, which are strong positive predictors of abuse, and may be the only skeletal manifestation.

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