Rib Fracture Follow-up

  • Author: Laurie K Mahoney, MD, FAAEM; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Jun 28, 2010
 

Further Inpatient Care

  • Patients with isolated rib fractures who are unable to cough and clear secretions adequately should be considered for admission for 24-hour observation.
  • Consider admission for patients with underlying lung disease or decreased pulmonary reserve.
  • A lower threshold for admission of older persons with isolated rib fractures is warranted because of their higher incidence of hypoventilation, hypercapnia, atelectasis, and pneumonia.[5]
  • Specifically in the age group 65 years and older, consider admission for patients age ≥ 85 years, or with initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 or more unilateral rib fractures, or pulmonary contusion.[5]
  • Admission may also allow for observation for occult intra-abdominal organ injury.
  • Patients being admitted should have good pain control and, if possible, given an incentive spirometer to prevent pulmonary splinting and its resultant complications.[24]
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Further Outpatient Care

  • Patients with minor rib injuries able to cough and clear secretions may be discharged with adequate analgesic medications.
  • Adequate analgesics are critical to successful outpatient management of rib fractures. In one study, 19% of patients discharged with the diagnosis of rib fracture returned to the ED for unplanned follow-up; the chief complaint was insufficient analgesia (in 56%).[25]
  • Most patients who will develop complications will do so within 2 weeks, so a follow-up plan within 2 weeks should be made.[25, 26]
  • Consider an incentive spirometer, especially with multiple fractures, as it may help avoid complications and remind the patient to avoid splinting and to take deep breaths.
  • One study of patients aged 65 years and older suggests that patients in this age group without risk factors may be safely discharged home. Risk factors are age ≥ 85 years, initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 of more unilateral rib fractures, or pulmonary contusion. Patients without these risk factors, with isolated blunt chest trauma, did not have an adverse event in this preliminary study (100% sensitivity, 38.5% specificity).[5]
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Transfer

  • Currently, no published guidelines exist for transfer of patients with simple rib fracture to a regional trauma center.
  • Some studies have concluded that the presence of 3 or more rib fractures identifies a subgroup of adult patients who may require tertiary care.
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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.

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Complications

Complications of rib fracture may include the following:

  • Hypoventilation
  • Hypercapnia
  • Hypoxia
  • Atelectasis
  • Pneumonia
  • Damage to underlying visceral organs
  • Pneumothorax (immediate or delayed)[25]
  • Hemothorax (immediate or delayed)[25]
  • Aortic injury (immediate or delayed)[27]
  • Pulmonary contusion
  • Intra-abdominal organ injury[14]
  • 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's syndrome.[2]
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Prognosis

  • Isolated rib fractures in younger patients have a good prognosis.
  • Older patients have a higher incidence of significant pulmonary complications. In one study, 16% of patients 65 years and older with isolated blunt chest trauma had some delayed adverse event, defined as pneumonia, ARDS, unanticipated intubation, need to transfer patient to ICU for hypoxemia, and death from pulmonary sequelae.[5]
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Contributor Information and Disclosures
Author

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.

Coauthor(s)

Christopher I Doty, MD, FACEP, FAAEM  Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Christopher I Doty, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency 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

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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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.
 
 
 
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