Emergency Department Care
Prehospital care should focus on airway maintenance and supplemental oxygen.
The goal of initial ED care is stabilization of the trauma patient and multisystem trauma evaluation.
Respiratory care, including use of incentive spirometry to prevent atelectasis and its complications, is often important. Holding a pillow or similar soft brace against the fracture site reduces discomfort while using the spirometer or when coughing.
Pain control is fundamental to the management of rib fractures to decrease chest wall splinting and alveolar collapse in order to clear pulmonary secretions. Isolated rib fractures, without associated injuries, may be managed on an outpatient basis with oral analgesics, starting with NSAIDs if not contraindicated and progressing to narcotics if not sufficient. A lidocaine patch for pain control has been used, but one study suggests its efficacy is no greater than placebo. [53] Other options include parenterally administered narcotics titrated to prevent respiratory depression. While rib belts or binders do control pain, they have been linked to hypoventilation, atelectasis, and pneumonia. As a result, their use is no longer recommended.
For patients with a significant mechanism of trauma, a CT of the chest and abdomen can be useful in scanning for significant related injury.
Several researchers have recommended hospital admission for any patient with 3 or more rib fractures and ICU care for elderly patients with 6 or more rib fractures. They cite the significant correlation between these findings and serious internal injuries, such as pneumothorax and pulmonary contusion. [54]
Patients with minor rib injuries who are able to cough and clear secretions may be discharged with adequate analgesic medications. Adequate analgesics are critical to successful outpatient management of rib fractures. [55] 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%). [56] Most patients who will develop complications will do so within 2 weeks, so a follow-up plan within 2 weeks should be made. [56, 57]
Routine follow-up chest x-rays days after the injury are not recommended. They add little besides cost to a careful clinical examination and should be performed only if indicated by clinical findings (eg, unilateral decreased breath sounds suggesting pneumothorax, persistent pain suggesting malunion or nonunion). [58]
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 or older, initial systolic blood pressure less than 90 mm Hg, hemothorax, pneumothorax, 3 of more unilateral rib fractures, or pulmonary contusion. Patients without these risk factors who had isolated blunt chest trauma did not have an adverse event in this preliminary study (100% sensitivity, 38.5% specificity). [33]
Because of the close association of rib fractures with injury to underlying structures, the ED physician may need to consult the trauma service.
Pain management specialists can be helpful for admitted patients.
Medical 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. [33]
Specifically for patients 65 years and older, consider admission for patients who are 85 years or older or who have initial systolic blood pressure less than 90 mm Hg, hemothorax, pneumothorax, 3 or more unilateral rib fractures, or pulmonary contusion. [33] 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. [59] A paravertebral block is only useful for patients with unilateral rib fractures but is associated with a lower rate of systemic hypotension. [60, 55]
Rib fractures can be very painful and cause splinting and compromise of respiratory function, which can lead to atelectasis, poor secretion removal, and ultimately pneumonia. Regional anesthesia has the potential to reduce suffering, decrease opiate use, lower rates of in-hospital delirium, and improve pulmonary function. Two single injection nerve blocks, the serratus anterior plane block (SAPB) and erector spinae plane block (ESPB), are particularly fast, safe, and simple methods to anesthetize the chest wall. [16, 61, 62, 63, 64, 65, 17, 66]
Intercostal nerve blocks provide pain relief without affecting respiratory function, although risks of this procedure include intravascular injection and pneumothorax. The procedure is also limited by the duration of the block and, for patients with multiple rib fractures, the need to perform the procedure at multiple intercostal levels. Intercostal nerve block has been shown to have the advantage of providing dramatically more effective pain control than conventional medications in the initial stage of treatment of patients with thoracic injuries. It is also relatively simple to use; is not associated with neurologic complications due to nausea, vomiting, dizziness, or bleeding; and is not associated with complications from possible misjudgment observed in other measures, such as thoracic epidural injection. [67, 55]
A meta-analysis of 8 studies (232 patients) in adult patients with traumatic rib fractures demonstrated no significant benefit for the use of epidural analgesia over other analgesic modalities on mortality, ICU admission, and hospital length of stay. Mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics may be beneficial, although hypotension was significantly associated with thoracic epidural analgesia. Further research and evaluation is needed regarding the benefits and harms of epidural analgesia in this population before being considered as a standard-of-care therapy. [68]
In a study of epidural analgesia versus paravertebral block for patients with rib fractures using information from the National Trauma Data Bank, neither procedure was found to be more beneficial; however, in patients who did not undergo either procedure, mortality was increased (odds ratio 2.25; 95% confidence interval, 1.14-3.84). [55]
In hospitalized patients, an intrapleural catheter placement may also be used for delivery of anesthetics directly into pleural cavity. The catheter used to administer the anesthetic can be placed adjacent to a thoracostomy tube at the time of tube placement. [69]
Patient-controlled analgesia pumps have also shown to be useful in hospitalized patients, allowing adequate pain relief with minimal inhibition of respiratory drive.
In a meta-analysis of 22 studies of patients with rib fractures who underwent open reduction and internal fixation (ORIF), ORIF was found to achieve lower mortality, shorter duration of mechanical ventilation and hospital length of stay, and a decreased incidence of pneumonia and the need for tracheostomy. [1]
Complications
Pneumonia is one of the most common complications associated with rib fractures. Pneumonia rates vary depending on the number of fractures and age of the patient. The incidence of pneumonia for all patients hospitalized with one or more rib fractures is about 6%. [70] In a placebo-controlled clinical trial of 204 elderly patients with a single rib fracture, oral administration of the probiotic Lactobacillus casei Shirota (LcS) for one month was associated with a lower incidence of pneumonia and increased pulmonary functions without causing severe adverse effects. [71]
The alteration in chest wall mechanics due to multiple rib fractures increases the work of breathing, and the patients with multiple rib fractures are at risk for pulmonary fatigue. Respiratory failure can be due to the chest wall injury (eg, flail chest) but is more commonly due to an underlying pulmonary contusion or development of nosocomial pneumonia, especially if superimposed on a preexisting pulmonary condition. [70]
Additional complications of rib fracture may include the following:
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Hypoventilation
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Hypercapnia
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Hypoxia
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Atelectasis
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Damage to underlying visceral organs
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Pneumothorax (immediate or delayed) [56]
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Hemothorax (immediate or delayed) [56]
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Retained hemothorax: Retained hemothorax refers to the presence of blood/clot in the thoracic cavity that persists in spite of thoracostomy drainage. The risk of empyema is increased in patients with retained hemothorax. [72]
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Aortic injury (immediate or delayed) [73]
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Pulmonary contusion
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Intra-abdominal organ injury [43]
Patients with fractured ribs and vital capacity of less than 30% have been found to have a higher rate of pulmonary complications. One study found that every 10% increase in vital capacity was associated with a 36% decrease in likelihood of pulmonary complications. Patients with a vital capacity greater than 50% had a significantly lower rate of pulmonary complications. [74]
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 syndrome. [20]
A small percentage of rib fractures do not heal even though a fibrous capsule may envelop the fracture. A nonunion may present months to years after injury and can cause discomfort with respiration due to movement of the fracture site. Some patients find the respiratory restriction due to pain quite disabling.
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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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Anteroposterior (AP) radiograph of an elderly female patient with severe left chest wall pain after a minor fall. This image demonstrates a left lateral rib fracture (arrow) that is not seen on the standard AP chest radiograph.
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Axial computed tomography image of the chest in a patient with both anterior and posterior thoracic injuries. A fracture of the sternum (white arrow) and a posterior left rib fracture (yellow arrow) are present.
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Right rib radiograph in a 48-year-old male who presented with severe right posterior chest wall pain following a fall. This image demonstrates 2 fractures of the right chest wall (white arrows).
