Rib fractures
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Rib fractures are a common consequence of trauma and can cause life-threatening complications.
Pathology
The 4th-10th ribs are the most commonly fractured 1. Fractures of the 1st-3rd ribs are associated with high-energy trauma 3.
When the rib is fractured twice, the term floating rib is used to described the free fracture fragment, and when three or more contiguous floating ribs are present this is called a flail chest.
Buckle rib fractures can also occur.
Aetiology
- blunt and penetrating trauma: e.g. motor vehicle accidents, falls, assaults
- most common injury in blunt thoracic trauma, occurring in 50% of cases 3
- pathological fractures
- stress fractures: occur more commonly in high-level athletes
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non-accidental injuries in children
- typically posterior fractures
- cardiopulmonary resuscitation (CPR): occurs in 1 in 3 5
- fetal rib fractures: caused by skeletal dysplasias
- radiation induced rib fractures 8-9
Associations
Rib fractures are often associated with other injuries and the greater the number of rib fractures the more likely are associated injuries 1, 3:
- brachial plexus or subclavian vessel injuries (1st-3rd rib fractures)
- pneumothorax/haemothorax
- pulmonary laceration
- lung herniation
- liver, kidney and spleen traumatic injuries (10-12th rib fractures)
Radiographic features
Plain radiograph
- may miss up to 50% of rib fractures even with dedicated oblique rib projections 1
CT
- more sensitive than plain radiography for the detection of rib fractures 1, 3
Ultrasound
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demonstrates cortical discontinuityCommon application of point of care ultrasonography,
linear edge shadow,used in a complementary manner to conventional radiography in the workup of blunt chest wall trauma andacoustic reverberation artefacts6 -
nolocalised chest pain. Ultrasonography is more sensitive and specific thanx-rayconventional radiography for rib fracture detection in blunt trauma when performed by a trained clinician 12, 14.Moreover, the use of sonography allows the detection of radiographically occult costal cartilage fractures, as well as assessment of the underlying lung for associated traumatic pathology, including;
B-mode
- cardinal sonographic feature is a discontinuity of the otherwise smooth, linear echogenicity corresponding to the anterior bony cortex
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if accompanied by cortical displacement, may be further characterised by the axial distance between the cortical margins 14
- separation by less than 1 mm defines mild displacement
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considered severe when > 4 mm
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often associated with
added disadvantagecomet tail artifacts extending from the fracture site into the far field
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often associated with
-
if initially occult, obvious interruption of
patient discomfortthe bony cortex may be elicited with sonopalpation (applying local transducer pressure)- appropriate analgesia may be necessary before attempting this maneuver
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suggestive findings include a circumscribed, hypoechoic fluid collection adjacent to the putative fracture site
-
represents a fracture hematoma, fluid nature may be ascertained through careful adjustment of gain settings and
increased examination time6 - associated periosteal elevation appears as a delicate, raised hyperechoic linear stripe
-
represents a fracture hematoma, fluid nature may be ascertained through careful adjustment of gain settings and
Nuclear medicine
- Tc99m bone scan is sensitive but not specific for rib fractures and demonstrates focal areas of high-uptake, which need to be correlated with SPECT or radiographic imaging 1, 7
Treatment and prognosis
Rib fractures themselves are treated symptomatically and have a good prognostic outcome. Rarely, severe rib injuries (e.g. flail chest) may be treated with ORIF, often in the setting of other severe traumatic injuries and in the hope that respiratory function will improve facilitating a shorter ICU stay and quicker recovery.
Complications
Aside from immediate traumatic complications outlined above atelectasis and pneumonia may develop, mainly due to poor respiratory effort secondary to pain, and this increases the morbidity and mortality due to rib fractures 3.
See also
-</li></ul><h5>Ultrasound</h5><ul>-<li>demonstrates cortical discontinuity, linear edge shadow, and acoustic reverberation artefacts <sup>6</sup>-</li>-<li>no more sensitive than x-ray with added disadvantage of patient discomfort and increased examination time <sup>6</sup>- +</li></ul><h5>Ultrasound</h5><p>Common application of point of care ultrasonography, used in a complementary manner to conventional radiography in the workup of blunt chest wall trauma and localised chest pain. Ultrasonography is more sensitive and specific than conventional radiography for rib fracture detection in blunt trauma when performed by a trained clinician <sup>12, 14</sup>.</p><p>Moreover, the use of sonography allows the detection of radiographically occult costal cartilage fractures, as well as assessment of the underlying <a title="Bedside lung ultrasound in emergency (approach)" href="/articles/bedside-lung-ultrasound-in-emergency-approach">lung </a>for associated traumatic pathology, including;</p><ul>
- +<li><a title="Pneumothorax (ultrasound)" href="/articles/pneumothorax-ultrasound-1">pneumothorax</a></li>
- +<li><a title="Lung contusion" href="/articles/pulmonary-contusion">lung contusion</a></li>
- +</ul><h6>B-mode</h6><ul>
- +<li>cardinal sonographic feature is a discontinuity of the otherwise smooth, linear echogenicity corresponding to the anterior bony cortex</li>
- +<li>if accompanied by cortical displacement, may be further characterised by the axial distance between the cortical margins <sup>14</sup><ul>
- +<li>separation by less than 1 mm defines mild displacement </li>
- +<li>considered severe when > 4 mm<ul><li>often associated with <a title="Comet tail" href="/articles/comet-tail-artifact-3">comet tail</a> artifacts extending from the fracture site into the far field</li></ul>
- +</li>
- +</ul>
- +</li>
- +<li>if initially occult, obvious interruption of the bony cortex may be elicited with sonopalpation (applying local transducer pressure)<ul><li>appropriate analgesia may be necessary before attempting this maneuver</li></ul>
- +</li>
- +<li>suggestive findings include a circumscribed, <a title="Ultrasound physics" href="/articles/physical-principles-of-ultrasound-1">hypoechoic</a> fluid collection adjacent to the putative fracture site <ul>
- +<li>represents a <a title="Hematoma" href="/articles/haematoma">fracture hematoma</a>, fluid nature may be ascertained through careful adjustment of gain settings and dynamic variation of the observed shape with pressure</li>
- +<li>associated periosteal elevation appears as a delicate, raised hyperechoic linear stripe </li>
- +</ul>
References changed:
- 10. Yousefifard M, Baikpour M, Ghelichkhani P, Asady H, Darafarin A, Amini Esfahani MR, Hosseini M, Yaseri M, Safari S. Comparison of Ultrasonography and Radiography in Detection of Thoracic Bone Fractures; a Systematic Review and Meta-Analysis. (2016) Emergency (Tehran, Iran). 4 (2): 55-64. <a href="https://www.ncbi.nlm.nih.gov/pubmed/27274514">Pubmed</a> <span class="ref_v4"></span>
- 11. Pishbin E, Ahmadi K, Foogardi M, Salehi M, Seilanian Toosi F, Rahimi-Movaghar V. Comparison of ultrasonography and radiography in diagnosis of rib fractures. (2017) Chinese journal of traumatology = Zhonghua chuang shang za zhi. 20 (4): 226-228. <a href="https://doi.org/10.1016/j.cjtee.2016.04.010">doi:10.1016/j.cjtee.2016.04.010</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28687342">Pubmed</a> <span class="ref_v4"></span>
- 12. Sirmali M, Türüt H, Topçu S, Gülhan E, Yazici U, Kaya S, Taştepe I. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. (2003) European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 24 (1): 133-8. <a href="https://www.ncbi.nlm.nih.gov/pubmed/12853057">Pubmed</a> <span class="ref_v4"></span>
- 13. Grassi W, Filippucci E, Busilacchi P. Musculoskeletal ultrasound. (2004) Best practice & research. Clinical rheumatology. 18 (6): 813-26. <a href="https://doi.org/10.1016/j.berh.2004.05.001">doi:10.1016/j.berh.2004.05.001</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15501184">Pubmed</a> <span class="ref_v4"></span>
- 14. Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute rib fracture. (1999) AJR. American journal of roentgenology. 173 (6): 1603-9. <a href="https://doi.org/10.2214/ajr.173.6.10584808">doi:10.2214/ajr.173.6.10584808</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/10584808">Pubmed</a> <span class="ref_v4"></span>
- 15. Turk F, Kurt AB, Saglam S. Evaluation by ultrasound of traumatic rib fractures missed by radiography. (2010) Emergency radiology. 17 (6): 473-7. <a href="https://doi.org/10.1007/s10140-010-0892-9">doi:10.1007/s10140-010-0892-9</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20652719">Pubmed</a> <span class="ref_v4"></span>
- 16. 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. (2003) European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 24 (4): 608-13. <a href="https://www.ncbi.nlm.nih.gov/pubmed/14500082">Pubmed</a> <span class="ref_v4"></span>
- 17. Martin VT, Zeng L, Nzengue JC, Mao L, Huang J, Peng X. The use of a portable ultrasound system in the surgical assessment of rib fractures in an elderly patient. (2018) Annals of medicine and surgery (2012). 36: 96-98. <a href="https://doi.org/10.1016/j.amsu.2018.10.017">doi:10.1016/j.amsu.2018.10.017</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30450203">Pubmed</a> <span class="ref_v4"></span>
- 18. Rainer TH, Griffith JF, Lam E, Lam PK, Metreweli C. Comparison of thoracic ultrasound, clinical acumen, and radiography in patients with minor chest injury. (2004) The Journal of trauma. 56 (6): 1211-3. <a href="https://www.ncbi.nlm.nih.gov/pubmed/15211127">Pubmed</a> <span class="ref_v4"></span>
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