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Ribs

Summary

Fracture Type

Management

Follow-up

Flail = 2 or more adjacent rib fractures in 2 or more places

Observation for respiratory compromise

Treatment of underlying lung injury, chest drain for Pneumothorax

Pain control, PCA

Ventilatory support, NIV, HFHNPO2, or invasive

Very rarely operative

Often part of polytrauma

Invariably require admission for pain control and respiratory support

Radiological rib fractures not flail

Pain control

Exclude underlying lung injury

Review regularly in community by GP

Follow up Chest X-ray if sudden change in symptoms

Recovery, pain often gets gradually worse until 7 days and improves over 3-6 weeks

Clinical rib fractures

Pain control

Exclude underlying rib injury

Review in community by GP

Follow up Chest X-ray if sudden change in symptoms

Recovery, pain often gets gradually worse until 7 days and improves over 3-6 weeks

Classification

  • Flail - 2 or more ribs with segmental fractures.
  • Other - May be radiological or clinical fractures based on the findings of point tenderness pain on inspiration and a likely mechanism.

Epidemiology

  • Flail - In younger patients as part of a major trauma, or the elderly with osteopenia.
  • Other - At any age but young and active and then elderly and osteopaenic is the bimodal distribution.

Presentation

  • Flail - Pain, respiratory difficulty and compromise, and haemopneumothorax. Examination will show paradoxical chest movements where the flail segment sucks in on inspiration, there may be obvious deformity and bruising and crepitations may be felt of subcuraneous. emphysema.
  • Other - Chest wall pain, worse on deep inspiration, point tenderness over the fracture and on springing the chest (should avoid springing the chest as it may cause displacement, further injury or unnecessary pain if sufficient force provided).

Imaging

  • Flail - Chest X-ray may not show all fractures but indicate underlying lung injury and harmopneumothorax. CT scan may be required in significant trauma.
  • Other - Chest X-ray is done to check for underlying pneumothorax, may not see rib fractures. Ultrasound using the linear probe can provide a diagnosis for prognosis and time to healing.

ED Management Options

  • Flail - Initially management of whole patient as ATLS/EMST guidelines, and within breathing that may mean urgent decompression of pneumothorax/haemothorax. Adequate analgesia may be difficult to attain, consider all options including local nerve blocks and ketamine in association with narcotic analgesia. Management of oxygenation can be by NIV support in the spontaneously breathing patient and more recently with High Flow Humidified Nasal Prong Oxygen. Close monitoring and admission to high acuity areas is required.
  • Other - Adequate analgesia, pain management plan, and breathing advice.
  • Elderly patients present a high risk and will normally be admitted for analgesia and physio review/respiratory management.

Referral and Follow Up Requirements

Fracture Type

Urgency

Follow-up

Flail

Often Trauma call

Admit trauma team/cardiothoracic depending on underlying and other injury

Other

Admit older patients

Younger within 48 hrs with GP or ED if GP not available

Admission elderly/respiratory co-morbidities for pain relief and physio with incentive spirometry. Fractures in high risk groups are associated with pneumonia and higher death rates

Discharge home on adequate analgesia with factsheet and advice GP follow up with referral back if required or concerns about pneumothorax or underlying infection

Potential Complications

  • Flail - Immediate are associated with haemopneumothoraces, other are neuralgia, pneumonia, and restrictive lung disease patterns.
  • Other - Pneumothorax, underlying collapse and consolidation due to hypoventilation from inadequate analgesia.

Patient Advice

Flail

  • Managed as per admitting team, maintaining adequate analgesia with PCA and other adjuncts essential.
  • ECI patient factsheets

Other

  • Pain from the fracture is usual for 2-3 weeks andwill require regular, then prn analgesia
  • Return to sport will depend on the sport:
    • Full contact sport >10-12 weeks
    • Non-contact sport as per pain 3-6 weeks, but increased risk of re-fracture.
  • ECI patient factsheets

Further References and Resources

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