Rib Fracture Workup

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

Laboratory Studies

  • Laboratory studies are generally not useful for evaluation of isolated rib fractures.
  • Consider obtaining urinalysis in cases of lower rib fractures, as hematuria may indicate associated renal injury.[14]
  • Tests of the pulmonary function (arterial blood gas measurements) are used to determine if the lungs have been contused but do not actually test for rib fractures.
Next

Imaging Studies

Chest radiographs

  • Anteroposterior (AP) and lateral chest films are used routinely to assist in the diagnosis of rib fractures, yet sensitivity as low as 50% has been reported. Delayed or follow-up radiographs can be very helpful.
  • Chest radiographs are much more useful in the diagnosis of underlying injuries, including hemothorax, pneumothorax, lung contusion, atelectasis, pneumonia, and vascular injuries.
  • Findings of sternal fracture[3] or scapular fracture[15] should increase suspicion for rib fractures.

Rib radiographs

  • Obtaining a rib radiograph series remains controversial, as the additional information rarely changes the clinical picture or alters treatment. This rib detail radiographs can be helpful in evaluation of the 1st and 2nd ribs and the 7th through 12th ribs. Formal plain radiographs can also be useful to document abuse for legal purposes.
  • Diagnostic sensitivity is higher in rib radiographs than in chest radiographs; however, with a high clinical suspicion, treat for fracture regardless of the radiographic result.
  • Aortic injury, as shown in the image below, 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. Aortic injury is closely associated with a wideninAortic 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.

Bedside ultrasonography

  • Bedside ultrasonography by emergency physicians has been described and provides rapid diagnosis with no radiation exposure.[16]
  • Advantages include diagnosis of fracture in unossified bone in children, and diagnosis of other rib fractures that may be missed on plain radiographs.[16] Small preliminary studies suggest that ultrasonography may be more sensitive than chest radiography in detecting rib fractures when physicians who perform the examination are comfortable using the technique.[17, 18, 19, 20]
  • The technique includes first clinically identifying the site of maximal tenderness, then using a high-frequency 7- to 12-MHz linear transducer aligned parallel to the long axis of the rib to detect any discontinuity of cortical alignment, seen as a break in the hyperechoic rib margin.[16]

Chest CT scan

  • A chest CT scan is more sensitive than plain radiographs for detecting rib fractures.[21] The modality can also provide information regarding the number of ribs involved.
  • If complications from rib fractures are suspected clinically or diagnosed by plain radiographs, a chest CT scan may be helpful to document specific injuries, to characterize extent of injury, and to plan for definitive management.
  • An associated CT scan of the abdomen with intravenous contrast should be considered in cases involving lower rib fractures with suspected or known injury to the liver and/or the spleen.

Angiography

  • Because first and second rib fractures are often associated with vascular injury, ED physicians should consider angiography for such patients, especially if symptoms and signs of neurovascular compromise are present. This is particularly important with posteriorly displaced fractures of the first 2 ribs, which have a much higher degree of association with abnormal angiographic findings than other rib fractures.
  • While first rib fractures previously were considered a strong risk factor for aortic injury, most authorities now believe that aortography and/or CT scan are not indicated without other evidence of injury, such as abnormal mediastinum.
Previous
Proceed to Treatment & Management
 
 
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

References

  1. 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].

  2. Lee SJ, Chu SJ, Tsai SH. Isolated Bilateral First-rib Fractures. J Emerg Med. Jul 21 2008;[Medline].

  3. Recinos G, Inaba K, Dubose J, et al. Epidemiology of sternal fractures. Am Surg. May 2009;75(5):401-4. [Medline].

  4. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. Dec 1994;37(6):975-9. [Medline].

  5. 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].

  6. 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].

  7. 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].

  8. Richardson JD, McElvein RB, Trinkle JK. First rib fracture: a hallmark of severe trauma. Ann Surg. Mar 1975;181(3):251-4. [Medline].

  9. 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].

  10. Hassan AN, Ballester J, Slater N. Bilateral first rib fractures associated with Horner's syndrome. Injury. May 2000;31(4):273-4. [Medline].

  11. 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].

  12. 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].

  13. Coris EE, Higgins HW 2nd. First rib stress fractures in throwing athletes. Am J Sports Med. Sep 2005;33(9):1400-4. [Medline].

  14. 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].

  15. 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].

  16. Chan SS. Emergency bedside ultrasound for the diagnosis of rib fractures. Am J Emerg Med. Jun 2009;27(5):617-20. [Medline].

  17. 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].

  18. 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].

  19. 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].

  20. Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures?. Injury. Jun 2004;35(6):562-6. [Medline].

  21. 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].

  22. 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].

  23. [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].

  24. Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma. Mar 2003;54(3):615-25. [Medline].

  25. 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].

  26. 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].

  27. 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].

  28. 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].

  29. Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD. Epidemiology of trauma deaths. Am J Surg. Jul 1980;140(1):144-50. [Medline].

  30. 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].

  31. 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].

  32. 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].

  33. 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].

  34. Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures?. Injury. Jun 2004;35(6):562-6. [Medline].

  35. 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].

  36. LoCicero J 3rd, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am. Feb 1989;69(1):15-9. [Medline].

  37. Love JC, Symes SA. Understanding rib fracture patterns: incomplete and buckle fractures. J Forensic Sci. Nov 2004;49(6):1153-8. [Medline].

  38. Newman RJ, Jones IS. A prospective study of 413 consecutive car occupants with chest injuries. J Trauma. Feb 1984;24(2):129-35. [Medline].

  39. 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].

  40. Ruddy RM. Trauma and the paediatric lung. Paediatr Respir Rev. Mar 2005;6(1):61-7. [Medline].

  41. 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].

  42. 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].

  43. Wilson JM, Thomas AN, Goodman PC, Lewis FR. Severe chest trauma. Morbidity implication. Arch Surg. Jul 1978;113(7):846-9. [Medline].

  44. 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].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.