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]
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]
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.
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.
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]
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]
Colosimo AJ, Byrne E, Heidt RS Jr, Carlonas RL, Wyatt H. Acute traumatic first-rib fracture in the contact athlete: a case report. Am J Sports Med. Jul-Aug 2004;32(5):1310-2. [Medline].
Lee SJ, Chu SJ, Tsai SH. Isolated Bilateral First-rib Fractures. J Emerg Med. Jul 21 2008;[Medline].
Recinos G, Inaba K, Dubose J, et al. Epidemiology of sternal fractures. Am Surg. May 2009;75(5):401-4. [Medline].
Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. Dec 1994;37(6):975-9. [Medline].
Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL, Ahmed SS. Factors associated with complications in older adults with isolated blunt chest trauma. West J Emerg Med. May 2009;10(2):79-84. [Medline].
Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. Jun 2000;48(6):1040-6; discussion 1046-7. [Medline].
Shorr RM, Rodriguez A, Indeck MC, Crittenden MD, Hartunian S, Cowley RA. Blunt chest trauma in the elderly. J Trauma. Feb 1989;29(2):234-7. [Medline].
Richardson JD, McElvein RB, Trinkle JK. First rib fracture: a hallmark of severe trauma. Ann Surg. Mar 1975;181(3):251-4. [Medline].
Logan PM. Is there an association between fractures of the cervical spine and first- and second-rib fractures?. Can Assoc Radiol J. Feb 1999;50(1):41-3. [Medline].
Hassan AN, Ballester J, Slater N. Bilateral first rib fractures associated with Horner's syndrome. Injury. May 2000;31(4):273-4. [Medline].
Peters ML, Starling SP, Barnes-Eley ML, Heisler KW. The presence of bruising associated with fractures. Arch Pediatr Adolesc Med. Sep 2008;162(9):877-81. [Medline].
Boele van Hensbroek P, Mulder S, Luitse JS, van Ooijen MR, Goslings JC. Staircase falls: high-risk groups and injury characteristics in 464 patients. Injury. Aug 2009;40(8):884-9. [Medline].
Coris EE, Higgins HW 2nd. First rib stress fractures in throwing athletes. Am J Sports Med. Sep 2005;33(9):1400-4. [Medline].
Holmes JF, Wisner DH, McGahan JP, Mower WR, Kuppermann N. Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma. Ann Emerg Med. Oct 2009;54(4):575-84. [Medline].
Murphy J, Nyland J, Lantry J, Roberts C. Motorcyclist "biker couples": a descriptive analysis of orthopaedic and non-orthopaedic injuries. Injury. Nov 2009;40(11):1195-9. [Medline].
Chan SS. Emergency bedside ultrasound for the diagnosis of rib fractures. Am J Emerg Med. Jun 2009;27(5):617-20. [Medline].
Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute rib fracture. AJR Am J Roentgenol. Dec 1999;173(6):1603-9. [Medline].
Kara M, Dikmen E, Erdal HH, Simsir I, Kara SA. Disclosure of unnoticed rib fractures with the use of ultrasonography in minor blunt chest trauma. Eur J Cardiothorac Surg. Oct 2003;24(4):608-13. [Medline].
Rainer TH, Griffith JF, Lam E, Lam PK, Metreweli C. Comparison of thoracic ultrasound, clinical acumen, and radiography in patients with minor chest injury. J Trauma. Jun 2004;56(6):1211-3. [Medline].
Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures?. Injury. Jun 2004;35(6):562-6. [Medline].
Magu S, Yadav A, Agarwal S. Computed tomography in blunt chest trauma. Indian J Chest Dis Allied Sci. Apr-Jun 2009;51(2):75-81. [Medline].
Ingalls NK, Horton ZA, Bettendorf M, Frye I, Rodriguez C. Randomized, double-blind, placebo-controlled trial using lidocaine patch 5% in traumatic rib fractures. J Am Coll Surg. Feb 2010;210(2):205-9. [Medline].
[Best Evidence] Carrier FM, Turgeon AF, Nicole PC, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. Mar 2009;56(3):230-42. [Medline].
Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma. Mar 2003;54(3):615-25. [Medline].
Shields JF, Emond M, Guimont C, Pigeon D. Acute minor thoracic injuries: evaluation of practice and follow-up in the emergency department. Can Fam Physician. Mar 2010;56(3):e117-24. [Medline]. [Full Text].
Misthos P, Kakaris S, Sepsas E, Athanassiadi K, Skottis I. A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma. Eur J Cardiothorac Surg. May 2004;25(5):859-64. [Medline].
Bruno VD, Batchelor TJ. Late aortic injury: a rare complication of a posterior rib fracture. Ann Thorac Surg. Jan 2009;87(1):301-3. [Medline].
Albers JE, Rath RK, Glaser RS, Poddar PK. Severity of intrathoracic injuries associated with first rib fractures. Ann Thorac Surg. Jun 1982;33(6):614-8. [Medline].
Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD. Epidemiology of trauma deaths. Am J Surg. Jul 1980;140(1):144-50. [Medline].
Colosimo AJ, Byrne E, Heidt RS Jr, Carlonas RL, Wyatt H. Acute traumatic first-rib fracture in the contact athlete: a case report. Am J Sports Med. Jul-Aug 2004;32(5):1310-2. [Medline].
Flagel BT, Luchette FA, Reed RL, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. Oct 2005;138(4):717-23; discussion 723-5. [Medline].
Fulda GJ, Giberson F, Fagraeus L. A prospective randomized trial of nebulized morphine compared with patient-controlled analgesia morphine in the management of acute thoracic pain. J Trauma. Aug 2005;59(2):383-8; discussion 389-90. [Medline].
Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. J Trauma. Jun 1990;30(6):695-700. [Medline].
Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures?. Injury. Jun 2004;35(6):562-6. [Medline].
Lee RB, Bass SM, Morris JA Jr, MacKenzie EJ. Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study. J Trauma. Jun 1990;30(6):689-94. [Medline].
LoCicero J 3rd, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am. Feb 1989;69(1):15-9. [Medline].
Love JC, Symes SA. Understanding rib fracture patterns: incomplete and buckle fractures. J Forensic Sci. Nov 2004;49(6):1153-8. [Medline].
Newman RJ, Jones IS. A prospective study of 413 consecutive car occupants with chest injuries. J Trauma. Feb 1984;24(2):129-35. [Medline].
Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg. Oct 1982;196(4):481-7. [Medline]. [Full Text].
Ruddy RM. Trauma and the paediatric lung. Paediatr Respir Rev. Mar 2005;6(1):61-7. [Medline].
Stawicki SP, Grossman MD, Hoey BA, Miller DL, Reed JF 3rd. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc. May 2004;52(5):805-8. [Medline].
Trinkle JK, Richardson JD, Franz JL, Grover FL, Arom KV, Holmstrom FM. Management of flail chest without mechanical ventilation. Ann Thorac Surg. Apr 1975;19(4):355-63. [Medline].
Wilson JM, Thomas AN, Goodman PC, Lewis FR. Severe chest trauma. Morbidity implication. Arch Surg. Jul 1978;113(7):846-9. [Medline].
Woodring JH, Fried AM, Hatfield DR, Stevens RK, Todd EP. Fractures of first and second ribs: predictive value for arterial and bronchial injury. AJR Am J Roentgenol. Feb 1982;138(2):211-5. [Medline].

