Rib Fracture

Rib Fracture

David Ray Velez, MD

Table of Contents

Anatomy
Presentation and Complications
Description/Definition
Diagnosis
Classification Systems
Treatment

Anatomy

Anatomy

  • 12 Ribs on Each Side
  • True Ribs (#1-7): Attach Directly to the Sternum by Costal Cartilage
  • False Ribs (#8-12): Do Not Attach Directly to the Sternum by Costal Cartilage
    • Costal Cartilage of Ribs #8-10 Unite Before Indirectly Attaching to the Sternum
    • Floating Ribs (#11-12): Do Not Attach at All

Fracture

  • Ribs #1-3 are the Most Difficult to Fracture and Require Significant Force
  • Ribs #4-10 are the Most Commonly Fractured
  • Ribs #11-12 are Mobile and More Difficult to Fracture

Pediatrics Have More Elastic Ribs than Adults and are Less Vulnerable to Rib Fracture

Rib Cage

Presentation and Complications

Presentation

  • Severe Pain – Worse with Deep Breathing and Movement
  • Shortness of Breath/Dyspnea
  • Clicking Sensation with Movement
  • Swelling or Ecchymosis
  • Palpable Deformity or Crepitus

Respiratory Splinting

  • Definition: Reduced Inspiratory Effort Due to Severe Pleuritic Chest Pain or Fear of Pain Upon Inspiration
    • Patients Therefore Only Take Rapid Shallow Breaths
    • Expiration – A Passive Process that Relies on the Elastic Recoil of the Lung
    • Inspiration – An Active Process that Requires Muscular Contraction
  • Results In:
    • Hypoventilation
    • Atelectasis
    • Pneumonia
    • Retained Secretions
    • Respiratory Failure
  • Can Quantify Dynamically with Incentive Spirometry (IS)
    • Goal: > 15 cc/kg Ideal Body Weight

Complications

  • Pulmonary Contusion – *See Pulmonary Injury
    • Initial CXR Underestimates and Worsens with Time and Fluid Resuscitation
  • Atelectasis – *See Atelectasis
  • Pneumonia (PNA)
  • Acute Respiratory Distress Syndrome (ARDS)
  • Respiratory Failure
  • Pneumothorax (PTX) – *See Pneumothorax (PTX)
  • Hemothorax (HTX) – *See Hemothorax (HTX)
  • Injury to Internal Organs – Heart, Spleen, Liver, Kidney, etc.
  • Chronic Pain
  • Significantly Increased Mortality

Morbidity and Mortality Significantly Increase Once > 6 Rib Fractures

Elderly

  • Rib Fractures are the Most Common Injury in the Elderly After Blunt Chest Trauma
  • Each Additional Rib Fracture Increases:
    • Risk of Death by 19%
    • Risk of Pneumonia by 27%
    • *Risk May Be Overestimated by Older Studies without Modern Imaging

Description/Definition

Complexity

  • Simple: Single Fracture Line Across the Rib with No Fragmentation or Comminution
  • Wedge: A Second Fracture Line that Does Not Span the Entire Rib Width
  • Complex: ≥ 2 Fracture Lines with ≥ 1 Fragment Spanning the Entire Rib Width

Displacement

  • Nondisplaced: ≥ 90% of the Fracture Cortical Surfaces are in Contact
  • Offset: Some Cortical Contact But < 90% of the Fracture Cortical Surfaces are in Contact
  • Displaced: No Cortical Contact Between Fracture Surfaces

Location/Area

  • Anterior: Anterior to the Anterior Axillary Line
  • Lateral: Between the Anterior & Posterior Axillary Lines
  • Posterior: Posterior to the Posterior Axillary Line

Flail Chest

  • Definitions:
    • Flail Segment: ≥ 3 Adjacent Ribs Fractured in ≥ 2 Places
      • *Some Texts Say ≥ 2 Adjacent Ribs Fractured in ≥ 2 Places
    • Flail Chest: Flail Segment with the Clinical Paradoxical Chest Wall Movement
  • Paradoxical Breathing: The Fractured Segment is Pulled Inward with Inhalation and Outward with Exhalation
    • Disrupts Normal Respiratory Mechanics
    • Collapse Causes Air Movement from the Injured Lung to the Uninjured Lung – Results in a Possible Mediastinal Shift to the Injured Side
  • Risk for Underlying Pulmonary Contusion
  • Initial CXR Underestimates and Worsens with Time and Fluid Resuscitation

Flail Chest 1

Diagnosis

Chest X-Ray (CXR)

  • CXR is Generally the Initial Imaging Modality After Chest Wall Trauma
  • Can Rapidly Evaluate for Other Life-Threatening Injuries (HTX/PTX)
  • Poor Sensitivity for Rib Fractures (33-40%) – Often Underestimates or Completely Misses

Chest CT

  • The Gold Standard for Rib Fracture Diagnosis
  • Identifies Significantly More Fractures and Thoracic Injuries than CXR
    • Over Half of Patients with Rib Fracture Find ≥ 3 More Rib Fractures on CT than CXR

Can Obtain 3D Reconstructions of Chest CT to Better Evaluate and Plan Surgical Intervention – Their Routine Use, However, Has Not Been Shown to Change Management or Improve Outcomes

Classification Systems

Rib Score

  • The Most Extensively Validated Scoring System
  • Based on Static Radiographic Data
  • Factors:
    • ≥ 6 Fractures
    • Bilateral Fractures
    • Flail Chest
    • ≥ 6 Severely (Bicortical) Displaced Fractures
    • First Rib Fracture
    • ≥ 1 Fracture in All Three Anatomic Areas (Anterior, Lateral, and Posterior)
  • Scores ≥ 4 Have Higher Risk for Pulmonary Complications (Pneumonia, Respiratory Failure, and Tracheostomy)

Sequential Clinical Assessment of Respiratory Failure (SCARF) Score

  • A Dynamic Physiologic Score Measured Daily
  • Factors:
    • Number Pain Score ≥ 5
    • Incentive Spirometry < 50% Predicted
    • Respiratory Rate ≥ 20
    • Poor Cough
  • Interpretation:
    • Score 0: Low Risk of Adverse Outcomes
    • Score 1-2: Intermediate Risk of Adverse Outcomes
    • Score 3-4: High Risk of Adverse Outcomes
  • Scores > 2 After Interventions Should Prompt Consideration for Increasing Analgesia Regimen

Other Scoring Systems

  • AAST Organ Injury Scale (OIS)
  • Rib Fracture Score (RFS)
  • Chest Trauma Score (CTS)
  • Thoracic Trauma Severity Score (TTSS)
  • Battle Score
  • Revised Intensity Battle Score (RIBS)
  • Rib Injury Guideline (RIG)

Treatment

Primarily Treated by Nonoperative Management

Consider ICU Admission for All Elderly Patients with Significant Fractures

Surgical Stabilization of Rib Fractures (SSRF)

  • Also Known as: Rib Plating or Open Reduction and Internal Fixation (ORIF) of the Ribs
  • The Use and Exact Indications for SSRF is Highly Debated and Evolving
  • Early Timing is Preferred as Prolonged Trials (7-10 Days) of Nonoperative Management for Multiple Displaced Rib Fractures Increases the Risk of Pulmonary Compromise
  • Potential Indications:
    • Flail Segment with Respiratory Failure or Poor Response to Nonoperative Management
    • Multiple Displaced Rib Fractures
    • Nonunion
    • Significant Deformity
    • Refractory Pain
    • Unable to Wean Off Ventilator
    • During Thoracotomy for Other Indication – “On the Way Out”
  • Generally Only Plate Ribs #4-9 – Where the Majority of Chest Wall Movement Occurs
    • Ribs #1-3 Have Little Movement and Are Difficult to Access
    • Ribs #10-12 Add Little to Chest Wall Stability

Pulmonary Contusion is Not a Contraindication to SSRF – Early Reports Advocated Against but Newer Data Shows Favorable Outcomes

Rib Plating 2

References

  1. Granhed HP, Pazooki D. A feasibility study of 60 consecutive patients operated for unstable thoracic cage. J Trauma Manag Outcomes. 2014 Dec 30;8(1):20. (License: CC BY-2.0)
  2. Evman S, Kolbas I, Dogruyol T, Tezel C. A Case of Traumatic Flail Chest Requiring Stabilization with Surgical Reconstruction. Thorac Cardiovasc Surg Rep. 2015 Dec;4(1):8-10. (License: CC BY-NC-SA-4.0)