Chest Case 14

46 YOM with no reported chronic medical problems presents after mechanical fall onto his right side. He is complaining of right sided flank/chest pain with deep inspiration. At presentation he is awake/alert in no respiratory distress. He has been otherwise well free of other injury or illness.

History and PhysicalT 98.9 P 90 BP

148/76 O2 99% RR 16

Gen: WDWNCV: RRR, no m/r/gPulm: Lungs CTA

bilat, BBSE, on examination of the chest wall the patient is tender to palpation over soft tissue swelling and ecchymosis in the right lower chest wall in the

Abd: s/nt/nd

Chest X-Ray

Diagnosis: Isolated Rib Fracture

PA lateral film of right ninth rib fracture. No PTX was present

CT from the same patient in the PA and lateral films above. This clearly shows the rib displacement near the liver on the right

Oxygen IV Fluids Adequate analgesia (with NSAIDs and opioid analgesics) and

pulmonary toilet are the mainstays of treatment Consider intercostal nerve blocks for more adequate pain

control Inpatient criteria:

are elderly have preexisting pulmonary disease or significant

comorbidities that would impair healing in an outpatient setting.

Flail chest injuries As above including strong consideration of ventilatory support

if: 3 or more associated injuries severe head trauma comorbid pulmonary disease age > 65 yrs. fracture of 8 or more ribs

ED Management

Diagnosis Rib fractures have the appearance of an abrupt discontinuity in the

smooth outline of the rib.  A lucent fracture line may be seen.  A common pattern for evaluating the ribs is to examine the posterior

portions of the ribs first, then the anterior portions, and finish by examining the lateral aspects of each rib.  If you see an abnormality, follow that rib in its entirety. 

If it is necessary to exclude a rib fracture, oblique rib detail films should be obtained.

Up to 50 percent of rib fractures (especially those involving the anterior and lateral portions of the first five ribs) may not be apparent on x-ray.

A rib fracture is a CLINICAL diagnosis Oblique films can be obtained to better define area of concern. The principal diagnostic goal with clinically suspected rib fractures is

the detection of significant complications: pneuomothorx, hemopneumothorax, pulmonary contusion, major vascular injury, etc..

Most common location of rib fracture is posterior in nature

Pearls

Significance of rib fracture The pain of rib fractures can greatly interfere with ventilation. Admit patients with fractured ribs for at least 24 to 48 h if they

cannot cough and clear their secretions adequately, especially if they are elderly or have preexisting pulmonary disease.

Fracture of the upper three ribs is associated with an increased risk of significant injury (often vascular) because of the excessive force needed to fracture these ribs.

Fracture of the lower three ribs can be associated with liver or spleen injury

Rib fractures in children should raise suspicion for child abuse given the compliance of the pediatric rib and the force needed to fracture one.

Pearls

Additional Images: Rib Fracture

Left 7th posterior rib fracture in a pediatric patient

Right first rib fracture

Additional Images

Flail Chest. Radiograph at left and CT at right demonstrate multiple rib fractures (white arrows) with some ribs fractured in two or more places (see CT scan). There is also a pulmonary contusion (red arrow), subcutaneous emphysema (yellow arrows) and a fracture of the left transverse process of the vertebral body imaged on the CT scan