Clinical Pathways
Clinical Pathways
Rib Fractures
Rib Fractures

Rib Fractures

Tags
Emerg. Med. Practice
Published
November 1, 2021
Author(s)
Patrick Maher, MD, MS

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Action

Patient presents with rib fracture

Decision

How many rib fractures does the patient have?

Background

Examination

For patients experiencing chest pain for whom rib fracture is a consideration or for patients being evaluated after blunt chest trauma, the history is critically important in forming the risk profile to determine the need for further imaging, the level of required pain control, and to inform patient disposition. Patients should be asked to describe symptoms such as dyspnea, chest pain, and fatigue, including the onset, severity, and alleviating and exacerbating factors. For patients presenting following traumatic events, the mechanism of injury should be elicited, including speed of impact, use of restraint systems (including seatbelts and airbags), history of loss of consciousness, and any recent drug or alcohol use. Past medical history should also be obtained, as prior cardiopulmonary conditions can pose higher risks for patients. Medications, particularly the use of any anticoagulant or antiplatelet agents, should be noted.

For patients with rib fractures, a full examination should include a complete chest wall, cardiac, lung, and abdominal examination, as well as a neurologic examination to evaluate for injury to underlying structures. Patients will typically be able to describe points of tenderness along their chest wall that will be painful on palpation. Movement of the upper extremities or trunk can also cause pain to affected areas. Visual inspection may demonstrate bruising, lacerations, abrasions, or deformity over a rib fracture. In patients with flail chest, the classic finding of paradoxical chest wall movement with respiration may be present, although it can be clinically occult.

X-ray

The most recent Appropriateness Criteria® from the ACR for minor chest trauma recommend the chest radiograph as the most appropriate initial imaging for patients following minor trauma with suspected rib fracture, noting that this study suffers from limited sensitivity, as low as 50%. (See Table 1.)

CT

For patients presenting after more-severe trauma, we suggest following imaging algorithms that include CT of the chest for suspected serious thoracic injury. In severe trauma, a negative physical examination for abdominal injury in the presence of lower thoracic rib fractures may not be sufficient to rule out abdominal solid organ injury, based on large case series. The ACR also recommends CT without intravenous (IV) contrast for evaluation of possible rib fracture following cardiopulmonary resuscitation.

Ultrasound

Studies of ultrasound for detection of rib fractures have suggested moderate sensitivity and specificity. Ultrasound does not deliver ionizing radiation to patients, but examination can require lengthy physician time and can cause pain by application of pressure by the ultrasound probe.

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References
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