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Emergency And Acute Medicine – Rib Fracture
Rib fractures result from either major or minor thoracic trauma and may be classified as traumatic or pathologic. Most commonly, they occur after blunt thoracic trauma such as falls, motor vehicle collisions, assaults, or cardiopulmonary resuscitation. Penetrating trauma is a less common cause. Ribs typically fracture at the point of impact or at the posterior angle, the structurally weakest portion. Stress fractures may occur in the upper or middle ribs from repetitive high-force activities such as golf, rowing, or throwing, as well as from severe coughing. Pathologic fractures may occur with minimal trauma in patients with osteoporosis, malignancy, or advanced age.
Children are less likely to sustain rib fractures due to the elasticity of their chest wall; therefore, the presence of rib fractures in infants or toddlers without an appropriate mechanism should raise concern for nonaccidental trauma, and a skeletal survey should be considered. Elderly patients are more susceptible not only to fractures but also to complications such as atelectasis, pneumonia, and respiratory failure. Morbidity and mortality in older patients are approximately twice that of younger individuals.
Patients typically present with localized chest wall pain that worsens with deep inspiration, coughing, or movement. Dyspnea and pleuritic chest pain may also be reported. Examination often reveals point tenderness, bony step-off, crepitus, localized edema, ecchymosis (including the “seat belt sign”), and splinting respirations. Breath sounds may be normal or diminished. Segmental paradoxical movement of the chest wall suggests flail chest due to multiple rib fractures. Hypoxia, tachypnea, and respiratory distress may be present in more severe cases.
Diagnosis is initially clinical and confirmed with imaging. Anteroposterior and lateral chest radiographs are commonly used but may miss up to 50% of rib fractures. Imaging is primarily performed to evaluate for associated intrathoracic injuries such as pneumothorax, hemothorax, pulmonary contusion, pneumomediastinum, or widened mediastinum. Pulmonary contusions may not be visible until 6 to 12 hours after injury. CT scanning is more sensitive for detecting rib fractures and internal injuries and may be required when significant trauma is suspected. Fractures of the first three ribs suggest high-energy trauma and possible vascular injury, while fractures of ribs nine through twelve may indicate intra-abdominal injury. Ultrasound is increasingly recognized as a useful diagnostic tool for rib and cartilaginous injuries.
The differential diagnosis includes rib contusion, intercostal muscle strain, pneumothorax, costochondral separation, sternal fracture, and nontraumatic causes of chest pain such as myocardial ischemia, pulmonary embolism, pericarditis, aortic dissection, costochondritis, gastrointestinal disorders, or herpes zoster.
Management focuses on pain control and maintenance of adequate ventilation. In the prehospital setting, airway support, supplemental oxygen, and analgesia are priorities. Most simple fractures require no structural stabilization. Adequate analgesia is essential to prevent splinting, atelectasis, and pneumonia. NSAIDs with or without opioids are first-line therapy, while parenteral opioids may be necessary for severe pain. Care must be taken not to exceed recommended acetaminophen dosing limits. Intercostal nerve blocks using 0.5% bupivacaine provide 6 to 12 hours of effective pain relief and are particularly helpful in patients with severe pain. Incentive spirometry and deep breathing exercises should be encouraged. Chest binders should be avoided because they restrict ventilation and increase the risk of pulmonary complications.
Patients with multiple fractures, advanced age, significant underlying pulmonary disease, or associated injuries may require hospital admission for monitoring, aggressive pulmonary toilet, and possibly thoracic epidural analgesia or patient-controlled analgesia. Endotracheal intubation is indicated in cases of severe hypoxemia or impending respiratory failure. ICU admission is recommended for elderly patients with six or more rib fractures.
Admission is also indicated for intractable pain, inability to clear secretions, compromised pulmonary function, displaced fractures, fractures of the first three ribs, or associated pneumothorax, pulmonary contusion, or intra-abdominal injury. Patients with stable pulmonary function, no associated injuries, and adequate pain control on oral analgesics may be discharged with strict return precautions for worsening shortness of breath, increased pain, fever, or cough.
Most rib fractures heal within approximately six weeks, although patients often resume normal activities sooner. Routine follow-up chest radiographs are not recommended. Clinicians must remain vigilant for underlying intrathoracic and intra-abdominal injuries, as morbidity correlates with the number of fractured ribs, associated injuries, and patient age. Ensuring effective pain control and adequate ventilation is the cornerstone of management.
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