Rib Fracture

Background

• Rib fractures are relatively common, usually occurring due to accidental high-impact chest wall trauma, but can also occur from low-impact trauma, repetitive motion injuries (stress fractures), nonaccidental trauma (such as child abuse), and underlying pathology.
• Risk factors for rib fracture include
  • ≥ 80 years old
  • low bone mineral density
  • history of radiation therapy
  • difficulty performing instrumental activities of daily living
  • history of rib or chest fracture
• In patients sustaining rib fracture through chest trauma, serious associated injuries may also occur including, but not limited to, airway obstruction, pneumothorax, hemothorax, flail chest, thoracic aorta disruption, and spinal fractures.

Evaluation

• Suspect rib fractures in patients with history of chest wall trauma (accidental or nonaccidental, blunt or penetrating).
  • The most common cause of rib fractures is accidental blunt chest wall trauma that is high-energy in nature, such as during motor vehicle accidents and falls from significant heights.
  • Low-energy impact fractures may also occur, especially in the elderly (as a result of increased forces on osteopenic ribs).
  • Stress fractures of the ribs may occur from minor, chronic, repetitive trauma (when abnormal forces are placed on normal bone).
• Although less common, pathological (atraumatic) rib fractures can also occur and should be suspected in patients with
  • malignant or benign conditions that may contribute to weakening of the ribs
  • pain symptoms consistent with rib fracture
• Confirm the diagnosis of rib fracture with imaging.
  • In patients with acute blunt chest trauma:
    • if significant trauma occurred, other injuries (beyond rib fractures) are likely present and should be evaluated and ruled out as clinically indicated (including through the use of blood tests)
    • if major blunt trauma (high-energy mechanism of injury) and suspected chest injuries in patients who are hemodynamically stable
      • any of the following modalities are usually appropriate for first-line imaging
        • computed tomography (CT) of chest with contrast
        • CT of whole body with contrast
        • CT angiography (CTA) of chest with contrast
        • x-ray trauma series
      • additional modalities which may be appropriate consist of
        • CT of chest without contrast
        • CT of whole body without contrast
    • if minor blunt trauma and suspected rib fractures (injury confined to ribs):
      • chest x-ray is generally initial imaging modality; x-ray with rib views may also be appropriate
      • if normal chest x-ray, normal exam, and normal mental status, additional modalities which may be appropriate consist of
        • CTA of chest with contrast
        • CT of chest with or without contrast
    • if rib fractures are confirmed, monitor closely for respiratory decompensation; risk factors include
      • oxygen saturation < 92% on room air
      • inability to perform incentive spirometry at > 1,000 mL or > 15 mL/kg
      • vital capacity < 1.4, or < 55% of predicted
  • In patients with suspected rib stress fracture:
    • chest x-ray is generally initial imaging modality
      • x-rays are typically negative early
      • signs of bone healing may occur ≥ 3 weeks after symptom onset
      • posteroanterior view is preferred, but rib views may also be appropriate
    • if initial x-ray is negative
      • repeating x-ray in 10-14 days is usually appropriate, unless immediate "need-to-know" diagnosis
      • magnetic resonance imaging (MRI) without IV contrast is also usually appropriate
      • other imaging modalities that may be appropriate include
        • CT without IV contrast
        • Tc-99m bone scan whole body with single-photon emission computed tomography (SPECT)
  • In patients with suspected pathological rib fracture:
    • chest x-ray (posteroanterior view) may be used as initial imaging modality
    • CT without contrast or bone scan may be used as complement to chest x-ray
    • additional modalities which may be appropriate consist of
      • x-ray with rib views
      • fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT of skull base to midthigh
• In children with posteromedial rib fractures of inexplicable cause
  • suspect nonaccidental fracture; particularly if other fractures are found in various stages of healing
  • see Child Abuse - Physical for additional information

Management

• Initial management of patients with acute thoracic trauma and rib fractures:
  • The Western Trauma Association (WTA) management algorithm for adults with > 2 acute rib fractures may be used to help determine optimal treatment setting, appropriate pain management regimen, and if surgical rib fixation is indicated.
  • If hemodynamic instability, provide fluid resuscitation.
  • Implement interventions for pain; often a multimodal approach is used.
    • Nonregional analgesia (primarily oral and IV analgesics) is generally used as the initial therapy for pain management for mild-to-moderate chest wall injury (including rib fracture).
    • Regional anesthetic techniques may be used in patients with chest wall injuries associated with a high risk of respiratory complications.
  • For patients with significant thoracic trauma, see Blunt Chest Trauma - Emergency Management, or Penetrating Thoracic Trauma in Adults.
• Nonoperative management of rib fractures:
  • Nonoperative management is the treatment of choice for most patients with traumatic rib fractures or stress fractures of the rib; patients with multiple displaced fractures or flail chest usually require surgical fixation.
  • The goals of nonoperative management are adequate pain control and aggressive respiratory care with early mobilization to facilitate avoidance of delayed complications.
  • Controlling pain helps decrease chest wall splinting and improve tolerance for respiratory therapy.
  • Respiratory therapy helps clear airway secretions and expand the lungs in an effort to prevent pneumonia, atelectasis, and respiratory failure.
  • Physical therapy involves early mobilization which is a key factor in preventing thrombosis, embolism, and pulmonary complications.
• Operative management of rib fractures:
  • Indications (including selection of fractures for repair), and contraindications for surgical stabilization of rib fractures:
    • Consider surgical stabilization of rib fractures in patients with
      • flail chest (Weak recommendation)
      • multiple, severe (bicortical) displaced rib fractures (Weak recommendation)
      • failure of early, optimal nonoperative management, regardless of fracture pattern (Weak recommendation)
      • chronic nonunion of rib fracture with persistent disabling pain refractory to nonoperative management (Weak recommendation)
    • Selection of fractures for repair:
      • The first, second, 11th, and 12th ribs are generally not repaired due to lack of benefit for stability or pain control; however, in highly select cases (such as significant displacement, vascular impingement, or local unmanageable pain) repair may be considered. (Weak recommendation)
      • Fractures within 2.5 cm of
        • transverse process should not be repaired (Strong recommendation)
        • costal cartilage may be repaired (by fixation to either the cartilage or sternum) (Weak recommendation)
      • Repair rib fractures sequentially, not in an “every other” rib approach. (Strong recommendation)
    • Contraindications for surgical stabilization of rib fractures:
      • relative contraindications, which should be evaluated on individual basis, include (Strong recommendation)
        • pulmonary contusion
        • traumatic brain injury
      • additional contraindications include
        • respiratory failure not related to chest wall injury
        • other injuries requiring prolonged intubation
        • patients unable to tolerate surgery
  • For surgical timing, perform surgical rib fixation within 72 hours of injury (as fractures are easier to reduce when inflammation and callus formation are minimized). (Strong recommendation)
  • For antibiotic prophylaxis:
    • Use weight-based antimicrobial prophylaxis with cefazolin, with appropriate intraoperative redosing (Strong recommendation).
    • In patients at risk for colonization with methicillin-resistant Staphylococcus aureus (MRSA), administer vancomycin for prophylaxis. (Strong recommendation)
  • For surgical technique:
    • Surgical rib fracture repair may be performed with an open or percutaneous approach.
    • Rib fixation may be performed using either external plates or intramedullary strut fixation. (Weak recommendation)
    • Coexisting injuries and fracture characteristics (such as lung herniation and > 10 mm fracture gap) are carefully considered and factored into surgical methods.
• Follow-up:
  • In patients with relatively minor chest wall trauma, potential for delayed onset of respiratory complications necessitates early follow-up; suggested time frame for follow-up is 2 weeks.
  • In patients with nondisplaced fractures or stress fractures of the rib
    • follow-up to ensure compliance with activity restrictions and ensure fracture severity has not progressed
    • signs of healing may take ≥ 3 weeks to become visible on repeat imaging
  • In patients who had surgical rib fixation
    • initial follow-up visit should be scheduled 1-2 weeks postoperatively, with chest x-ray obtained prior to appointment; stopping or tapering narcotics should also be discussed at this time. (Strong recommendation)
    • consider additional follow-up visits at 3, 6, and 12 months after discharge, with a chest x-ray obtained to assess hardware positioning