You are in: eMedicine Specialties > Radiology > MUSCULOSKELETAL Rib, FracturesArticle Last Updated: Jan 16, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 13
  Author: Lennard A Nadalo, MD, Clinical Professor, Department of Radiology, University of Texas Southwestern Medical School; Consulting Staff, Envision Imaging of Allen and Radiological Consultants Association Lennard A Nadalo is a member of the following medical societies: American College of Radiology, American Society of Neuroradiology, American Society of Pediatric Neuroradiology, Radiological Society of North America, and Texas Radiological Society Coauthor(s): Kory Jones, MD, Staff Physician, Department of General Surgery, Methodist Medical Center Editors: Leon Lenchik, MD, Director, Densitometry Minifellowship, Assistant Professor, Department of Radiology, Wake Forest University Medical Center; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Theodore E Keats, MD, Professor, Departments of Radiology and Orthopedics, University of Virginia School of Medicine; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington Author and Editor Disclosure Synonyms and related keywords: cracked ribs, broken ribs, chest wall trauma, chest-wall trauma, crushed chest injury, chest trauma, thoracic trauma, blunt chest trauma, flail chest, pneumothorax, hemothorax, hemopneumothorax INTRODUCTIONSection 2 of 13
  BackgroundThoracic trauma may present as an isolated rib fracture, a chest contusion, or a laceration; however, significant thoracic trauma often involves multiple organ systems and several anatomic regions. The chest trauma that results from a motor vehicle accident may result in injury to the sternum, the ribs, and the heart, aorta, and lungs. PathophysiologyWith normal respiration, the sternal ends of the ribs rise and fall, whereas the vertebral ends remain fixed. The ribs are elevated with the synchronous contraction of the intercostal muscles. This muscular contraction elevates only the sternal ends, moving the sternal ends of the ribs up and away from the vertebral column to increase the anteroposterior (AP) distance. Changes in thoracic pressure generate pressure gradients that are necessary for air movement into and out of the lungs. The process of breathing requires the use of both the bony structures and accessory muscles; fractured ribs reduce this dual action and, therefore, reduce the volume of air that flows into and out of the lungs. Children seem less vulnerable to rib fractures than adults are because of the elasticity of their thoracic cage. Rib fractures in children who are not involved in a motor vehicle or pedestrian accident may be associated with child abuse.8, 9 Rib fractures among neonates and young children may be associated with genetic or physiologic disorders.10, 11 The frequency of rib fractures increases with increased brittleness of the chest wall, which increases with age. In elderly or chronically ill patients, rib fractures may occur with severe coughing or hard straining; these injuries are stress fractures. Hyperparathyroidism and glucocortical steroid administration are associated with an increased incidence of rib fractures.12, 13, 14 Other less common causes of rib fractures include gunshot wounds and other penetrating wounds of the chest (see Images 33-34). Rib fractures can compromise ventilation by causing pain, which can prevent proper ventilation and coughing.15, 16 This impairment may result in atelectasis, retained secretions, and pneumonia.17, 18 Multiple rib fractures can cause flail chest, which may result in ventilatory insufficiency due to ineffective respiratory action.19, 20 Broken ribs can penetrate the lungs and pleura, resulting in a hemothorax or a pneumothorax.4, 21, 22 In special clinical circumstances, rib fractures may occur without the effects of an acute injury. Stress fractures of the ribs have been associated with repetitive mechanical movement of the upper extremities, as seen in the sports of rowing and golf.23, 24 The occurrence of stress fractures among rowers has been reported to range from 6.1% to as high as 12%.23 Spontaneous pathologic fractures may occur in metastatic disease and severe metabolic disease such as hyperparathyroidism.12, 14, 25 FrequencyUnited StatesRib fractures are estimated to be present in 10% of all traumatic injuries and 14% of all chest-wall injuries. The most common injury of the chest is a fracture of 1 or more ribs, including a separation of the costochondral junction. In adults, rib fractures are the most common blunt chest injury, in which the middle and lower ribs, the fifth to ninth ribs, are the most commonly fractured. In one study, following the occurrence of a low-trauma fracture, the reported relative risk of a second fracture in older women was 1.95 compared with a 3.7 relative risk of a second fracture in an older adult male.26 Mortality/Morbidity
RaceNo important racial differences in the occurrence of rib fractures are reported. SexExcept for occupational risks related to physical labor and violent sports, rib fractures occur equally in young men and women. However, more older women than older men tend to have rib fractures.26 Age
Related eMedicine topics: AnatomyThe ribs are relatively flat elastic arches of bone (see Images 1-2) that form a large part of the thoracic skeleton. In general, 12 ribs occur in matched pairs on either side (see Images 5 and 7-8). The number of ribs may vary with the development of a cervical rib or a lumbar rib, or their number may be diminished to 11 as an anomaly and in certain conditions (eg, Down syndrome). The first 7 ribs are connected with the vertebral column behind and with the sternum in front by means of the costal cartilages. The first 7 ribs are called true, or vertebrosternal, ribs (see Images 5 and 7-8). Of the remaining 5 ribs, the first 3 have cartilages that are attached to the cartilage of the rib above; these are the vertebrochondral ribs (see Image 4). The last 2 ribs are free anteriorly. The 11th and 12th ribs are termed floating or vertebral ribs (see Images 6-7). The ribs vary in directional orientation; the upper ribs are less oblique than the lower ribs. Between each rib is an intercostal space. The ribs increase in length from the first to the seventh; the 12th ribs are generally the shortest. The first, second, and 10th-12th ribs present variations that require special consideration. The first rib is the most curved and the shortest of the ribs (see Image 3)—although the 12th rib may be shorter than the first rib—and the anterior portion of the first rib is larger and thicker than the other ribs. The general shape of the first rib is broad and flat, with a small and rounded head and a single articular facet (for articulation with the body of the first thoracic vertebra), but without an angle. The upper surface of the rib's body is marked by the scalene tubercle and the grooves that transmit the subclavian vein, the posterior subclavian artery, and the lowest trunk of the brachial plexus. Behind the posterior groove is an attachment for the scalenus medius muscle. The undersurface of the first rib is smooth without a costal groove. The second rib is longer than the first and follows a similar curvature. A minor angle is situated close to the tubercle, and the external surface of the second rib is convex. The body is not twisted, nor is it flattened horizontally like that of the first rib. The superior surface of the second rib provides the origin of the lower part of the first digitation and the whole of the second digitation of the serratus anterior muscle. A short costal groove is present. The 11th and 12th ribs each have a single articular facet on the head. They have no necks or tubercles. The distal ends of the lower 2 ribs are pointed at their anterior ends. The 11th rib has a slight angle and a shallow costal groove. The 12th rib may be shorter than the first rib. Each rib (except for the last 2) has 4 ossification centers: a primary center for the body and 3 epiphyseal centers. However, the 11th and 12th ribs only have 2 ossification centers. Toward the end of the second month of fetal life, the sixth and seventh ribs are the first to develop, and ossification first begins near the rib angle. The epiphyses for the head and tubercle make their appearance between the 16th and 20th years of life, and they are united to the body at about the 25th year. The important anatomic relationship of the ribs to the surrounding structures includes the thoracic nerves and the intercostal arteries and veins. The anterior divisions of the thoracic nerves are situated between the ribs—except for the 12th thoracic nerve, which passes below the 12th rib. Each nerve is connected with the adjoining ganglion of the sympathetic trunk by a gray and a white ramus communicans. The intercostal nerves are distributed to the thorax and abdomen. No plexus formation is present. The percutaneous distribution follows dermatome patterns. The sternum consists of the manubrium, body, and xiphoid process (see Image 7). The manubrium is attached to the sternum by a cartilaginous union until advanced age and articulates with the clavicle on each side. The angle made by the union of the sternum and the manubrium is the sternal angle; this is the level where the cartilage of the second rib articulates with the manubrium. The cartilage of the seventh rib joins the sternum at the junction of the body and the xiphoid. The body develops from 4 separate ossification centers. Related Medscape topics:Resource Center Genomic Medicine Resource Center Growth and Development Clinical DetailsFractures of the first rib Fractures of the first rib are extremely rare and more commonly associated with either multiple rib fractures or life-threatening injuries. Historically, fractures of ribs 1-3 have been associated with injuries of the brachial plexus and major vessels. Angiography, or arteriography, should be considered in stable patients with first rib fractures if there are absent or decreased upper extremity pulses, hemorrhage, and/or brachial plexus injury. Additional criteria for angiography include displacement of bone fragments and multiple thoracic injuries. Fractures of the first rib imply a violent force; this pattern of fractures may signify injury to the adjacent subclavian vein and brachial plexus. Isolated first rib fractures are seen in association with cranial and maxillofacial injuries and are probably secondary to avulsion of the first rib by its muscular attachment rather than direct trauma to the rib, which is relatively protected. Surfer's rib is an isolated first-rib fracture and occurs in surfers who perform the lay-back maneuver. Fractures of the first rib have also been associated with thoracic outlet syndrome.27 Fractures of the fifth to ninth ribs Fractures of the fifth to ninth ribs can be single or multiple. Multiple fractures can present as flail chest, which is present when paradoxical respiratory movement occurs in a segment of the chest wall. This type of fracture requires at least 2 segmental fractures in each of 3 adjacent ribs, the costal cartilages, or the sternum (see Image 14). Posterior flail segments are easier to manage clinically because of the presence of strong muscular and scapular support and because of a patient's natural tendency to lie with his or her back against the mattress. An inward displacement of the fracture fragments at the time of the injury may lacerate the lung parenchyma and produce a pneumothorax, with bleeding into the pleural cavity. The occurrence of a pneumothorax and hemothorax may be delayed for hours to days after the injury.4 Hemothorax of a significant degree that occurs with rib fractures is usually a result of laceration of an intercostal artery rather than bleeding from the lung. This bleeding can be life threatening. A spontaneous fracture of a midthoracic rib should alert the physician for an underlying metastasis or hyperparathyroidism. Fractures of the tenth to the twelfth ribs Pneumothorax A pneumothorax is a common sequela of blunt trauma. Fracture fragments that lacerate the lung parenchyma can cause bleeding into the pleural cavity and result in a pneumothorax (see Image 13). Hemothorax The incidence of hemopneumothoraces in patients with rib fractures is 30%. A hemothorax is usually the result of a lacerated intercostal artery; however, bleeding from broken ribs usually stops before a sufficient volume is lost and before emergency thoracotomy is required. Note: About 400-500 mL of blood may be hidden by the diaphragm on an upright chest radiograph, and 1 L or more of blood may be overlooked on a supine image. The bleeding may be delayed or may recur after several days. In a review by Simon et al, 12 cases of delayed hemothorax were identified, and 92% of those occurred in patients with multiple or displaced rib fractures.4 The presentation of hemothorax in these cases occurred between 18 hours and 6 days after the injury. Eleven of the affected patients complained of new-onset pleuritic chest pain and dyspnea; the symptoms were similar to those of a pulmonary embolism. Pulmonary contusion Rib fractures are associated with pulmonary contusions in 20-40% of cases. The injury is characterized by capillary disruption that results in the presence of intra-alveolar and interstitial hemorrhage, edema, protein, and fluid obstruction of the small airways with leukocyte infiltration. Serial chest radiographs obtained beginning right after the injury show a fluffy infiltrate that progresses in extent and opacity over 24-48 hours. Pulmonary contusions are often a part of a major chest injury that includes 1 or more fractures of the thoracic cage, a pneumothorax, and a hemothorax. The contusions may occur due to the transmission of force through the chest wall with minimal fractures of the ribs or sternum; this mechanism is especially seen in the young. In middle-aged or elderly patients, pulmonary contusions are usually accompanied by multiple rib fractures. Aortic injuries The idea that thoracic cage injuries are predictive of acute traumatic aortic tears is controversial. A study by Lee et al concluded that no clinically relevant correlation exists between these injuries and acute traumatic aortic tears.31 The authors also concluded that upper rib fractures are not an indication for aortic angiography. An aortic injury that is related to blunt trauma is usually due to the transmission of a shearing force at the ligamentum arteriosum.32 However, there have been case reports that describe fractured ribs puncturing the aorta.33, 34 One such case involved a posterior fracture of the left sixth rib that lacerated the aorta 3 days after the trauma occurred.35 Cardiac perforation may result in both pericardial and periaortic hemorrhage.36 Direct penetration of the heart due to a rib fracture has been reported.2 Flail chest A flail chest is present when a paradoxical respiratory movement occurs in a segment of the chest wall, the result of at least 2 segmental fractures in each of 3 adjacent ribs or costal cartilages (see Images 14-16). The incidence of flail segments is 10-15% in patients with major chest trauma. More severe injuries, such as closed head injury and intrathoracic injury, are common in the presence of a flail chest. Multiple fractures of the upper chest with a dislocation of the clavicle are also associated with extrathoracic lung herniation.21 However, in most cases, no chest-wall defects are present. Flail chest may lead to respiratory failure secondary to the pulmonary contusion and pain during inspiration. Treatment consists of chest-wall stabilization37; reduction of the respiratory dead space; management of the pulmonary contusion; and, most of all, pain control. Epidural analgesics are the pain-management agents of choice.16 Intercostal nerve blocks may also be used. The extent of a pulmonary contusion and whether pain management allows for proper pulmonary toilet determine the need for mechanical ventilation. Surgical stabilization is rarely indicated; however, Lardinois et al found that early restoration of the integrity of the chest wall by using reconstruction plates in anterolateral flail chests may be cost effective.19 Abdominal solid-organ injury Low rib fractures, right-sided rib fractures, female sex, young age, and an elevated injury severity score increase the probability of a liver injury. Low rib fractures, rib fractures on only the left side, young age, and an elevated injury severity score increase the probability of a splenic injury. In a study by Shweiki et al, the incidence of liver injuries was 10.7% in their population of patients with rib fractures, and 11.3% had splenic injuries.28 Preferred ExaminationThe patient's medical history and physical examination findings should suggest the diagnosis of a rib fracture. The primary signs and symptoms are a pleuritic-type chest pain and tenderness over fracture site. When 2 or more adjacent ribs are fractured, especially if they are broken in more than 1 place, examination alone should be enough to enable a presumptive diagnosis of a rib fracture. The standard chest radiograph is useful in the recognition of preexistent or coexistent disease. The routine radiographic examination of the sternum includes the frontal prone and rotated views in an off-lateral projection. However, approximately 50% of all rib fractures go undetected during screening chest radiography (see Images 9-10).38, 39 The examination of suspected rib fractures should include the acquisition of erect posteroanterior (PA) and oblique radiographs of the chest (see Image 11). An erect frontal examination of the chest is useful in the detection of a pneumothorax, pulmonary contusion, or pleural effusion. Each oblique projection is intended to depict the entire rib. The PA chest radiograph alone is ineffective in the identification of incomplete or minimally displaced rib fractures; the lower ribs may be obscured by the upper abdominal organs. If a lower rib fracture is suspected, a radiographic technique is required that centers an AP radiograph of the lower portion of the chest and upper abdomen on the upper lumbar spine film. If the patient remains symptomatic despite a negative initial radiograph, a repeat radiograph of the ribs, acquired with a standard technique, often demonstrates the signs of early healing of a rib fracture. If the identification of occult rib fractures is clinically important, as in a case of suspected child abuse or for medicolegal reasons, radionuclear bone scanning with technetium-99m methylene diphosphonate (99mTc MDP) is often successful. A delay of several days should be allowed after an acute trauma to increase the sensitivity of radionuclear imaging for a rib fracture. Limitations of Techniques
DIFFERENTIALSSection 3 of 13
[Lung, Trauma] Aorta, Trauma Child Abuse Hyperparathyroidism, Primary Tracheobronchial Tear Vascular and Solid Organ Trauma - Interventional Radiology Other Problems to Be ConsideredBlunt Chest Trauma RADIOGRAPHSection 4 of 13
FindingsThe most common radiographic presentation of rib fractures is that of a minimally displaced, irregular lucent line across the cortex of the involved rib. Secondary findings of rib fractures include a localized extrapleural hematoma, which is seen as a focal pleural opacity. Most rib fractures are better seen on a tangent; posterior and anterior oblique projections are often necessary to detect minimally displaced rib fractures (see Images 9-11). A small focal pneumothorax or the presence of subcutaneous air (see Images 12-13) may be the only initial radiographic sign of a rib fracture. A large pneumothorax may result in the shift of the trachea or other mediastinal structures away from the injury (see Image 17). A fracture of the manubrium may be accompanied by presternal hematoma. Injury to the sternum is best evaluated with lateral and oblique views that are centered on the sternum. After calcification, fractures of the costal cartilages may be detected by radiographs obtained in an anterior oblique projection. Widening of the mediastinum suggests the possibility of both an aortic injury and associated rib or sternal fractures. In cases of suspected mediastinal bleeding, a lateral radiograph of the sternum can help to confirm a serious chest injury. Degree of ConfidenceBlunt trauma to the chest may result in incomplete or nondisplaced rib fractures. Such injuries may not be visible on the initial chest radiographs. AP supine chest radiographs often fail to demonstrate rib detail. Approximately 10-15% of rib fractures are not visible on the standard chest image. False Positives/NegativesAP supine chest radiographs often fail to demonstrate rib detail. False-positive readings for rib fractures are associated with superimposed bowel gas over the lower ribs, resulting in the appearance of a lucent line that is not the result of a rib fracture. The costal-cartilage junction is often misinterpreted as a fracture. Artifacts due to clothing, skin folds, and intravenous (IV) lines can also lead to false suggestions of rib fractures. CT SCANSection 5 of 13
FindingsEach thoracic CT examination that is performed for the evaluation of trauma offers an opportunity to diagnose rib fractures. A direct sign of a rib fracture on an axial CT scan of the chest is the separation of 2 rib fragments with the associated sharp edges. The secondary findings related to rib fractures include a hemothorax (see Image 20), pneumothorax (see Image 18), and lung contusion (see Image 19). These findings are more easily seen on chest CT scans than on chest radiographs (see Image 21). All chest CT scans should be reviewed with a bone window setting, one that emphasizes the internal lung detail. The application of a bone CT scan algorithm increases the likelihood of finding fractures. Every effort should be made to decrease patient movement and breathing-related artifacts. The areas contiguous with pulmonary contusions and localized bleeding should be carefully examined for rib fractures as well. With improvements in the resolution of CT scanners, the thoracic spine can be examined for fractures by using chest CT images (see Image 22). Gas in the epidural space can arise via a thoracic spinal fracture that is associated with a pneumothorax (see Images 22-24). Associated injuries to the internal organs of the upper abdomen should be considered in all cases of lower rib fractures; posterior lower rib fractures are often complicated by splenic injury (see Images 26-27). Fractures of the posterior upper thorax may be complicated by associated scapular fractures (see Image 28). In severe motor vehicle accidents, both anterior and posterior rib fractures may be seen in the same patient (see Image 31). Multiple systemic trauma may lead to prolonged hypotension or hypoxia. Multiple cerebral infarcts may result from cerebral hypoxia or as a complication of direct cranial trauma (see Image 32). Sternal fractures require special care. A clinically important fracture of the sternum may be seen on just a single axial CT image of the chest (see Image 29). Secondary findings of bleeding in the anterior mediastinum and possible aortic injury are important related patterns (see Image 30). Degree of ConfidenceRib fractures that are seen on standard radiographs are not always clearly demonstrated on conventional CT images. However, 2-mm-thick scan sections with a bone technique will demonstrate nearly all rib fractures. CT examinations performed with a multislice scanner allow faster scans, thinner sections, and less motion artifacts. In selected cases, multiplanar reformatted images may be helpful. False Positives/Negatives
MRISection 6 of 13
FindingsAlthough magnetic resonance imaging (MRI) is not used as a primary means of detecting rib fractures, displaced or angulated lateral rib fractures as well as posterior rib fractures can be detected by MRI. Anterior chest wall movement with breathing may limit the visualization of nondisplaced fractures. Gradient-echo MRI, T2 fast-spin echo (FSE), and T2 short tau inversion recovery (STIR) sequences demonstrate the edema that is related to rib fractures. Spinal fractures may be associated with secondary effects of posterior rib fractures such as hemorrhage and edema. Lower cervical spine injury may be associated with fractures of the first or second ribs. Degree of ConfidenceMRI is not a primary imaging modality for the diagnosis of rib fractures. However, posterior fractures of the ribs are commonly demonstrated on spinal MRI. False Positives/NegativesBreathing motion can cause artifacts, resulting in nondiagnostic MRIs of anterior rib fractures. Partial-volume effects may result in a false suggestion of a nondisplaced rib fracture. ULTRASOUNDSection 7 of 13
FindingsDirect visualization of rib fractures is generally not possible with ultrasonography. However, the presence of a hemothorax can be confirmed with ultrasonography of the pleural space, and edema in the chest-wall muscles may be seen as thickening of the pleural space, as well as the alteration of the ecogenic pattern within the chest-wall muscles. Degree of ConfidenceThe primary detection of rib fractures with ultrasonography is not useful. Hemothorax cannot be consistently differentiated from a pleural effusion. The visualization of a splenic or hepatic hematoma may indirectly suggest a search for a rib fracture. False Positives/NegativesUltrasonography is not effective in the visualization of a pneumothorax, small pleural effusions, and nondisplaced rib fractures. NUCLEAR MEDICINESection 8 of 13
FindingsNuclear medicine techniques are useful in the detection of subacute rib fractures, as well as costochondral separations. The bone-seeking 99mTc-labeled phosphonates are selectively distributed into the areas that surround healing rib fractures. The dose of 99mTc-medronate is usually 800 megabecquerels (MBq). Imaging is generally performed after a 4-5 hour delay to allow the clearing of the diagnostic agent from the blood pool. If a localized lesion is under investigation, regional blood flow can be evaluated with a 3-phase study in which a flow phase, a blood-pool image, and delayed static images are obtained. The flow phase is obtained immediately. The static images are generally obtained 4 hours after the administration of the diagnostic agent. Increased regional nuclear activity within a chest-wall contusion may be detected on immediate imaging. A positive result for a rib fracture is represented by a focal area of increased nuclear activity. In the case of a linear fracture, the increased activity is localized to the site of the injury. If a large area of the chest wall is injured, several ribs in multiple locations may demonstrate an increased uptake of the radionuclide.42 Degree of ConfidenceIncreased radionuclide uptake in the area of chest-wall trauma indicates a rib fracture in most cases. The application of lateral, oblique, and single-photon emission computed tomography (SPECT) imaging techniques improve diagnostic accuracy. Standard radiographs and the results of CT scans of the chest should be compared with bone scans whenever possible. Positive results with radionuclide imaging require a moderate degree of cooperation from the injured patient. Movement, including rapid breathing, results in poor image quality and decreased sensitivity. A rib fracture is generally seen as a site of increased nuclear activity after a short (12- to 24-h) delay in a young patient. In older patients and in patients with metabolic bone disease, fractures may not be visible until 72 hours after an injury. Except for pathologic fractures, a bone scan that is directed toward the detection of rib fractures should be delayed 48-72 hours following the traumatic event. False Positives/NegativesNormal costochondral uptake in a child may be intense enough to suggest rib stippling when viewed from a posterior projection. Any disease or lesion of a rib that results in increased bone turnover may result in positive findings in the ribs. False-negative results may occur in patients who have recently received iron dextran injections. High levels of iron in the bone marrow interfere with the normal uptake of bone. Fractures or other lesions of the ribs may not be detected until the iron storages return to normal. ANGIOGRAPHYSection 9 of 13
FindingsSelective angiography has a limited role in the evaluation of rib fractures. Thoracic angiograms may show a traumatic pseudoaneurysm or the extravasation of contrast material into the pleural space. Complications in cases of multiple trauma may include central vascular injury (aortic tear) and laceration of the subcostal artery. Direct visualization of active hemorrhage that is associated with a rib fracture is useful in the direction of surgical or angiographic intervention. Diagnostic angiography may be helpful in demonstrating a remote vascular injury and the delayed development of a pseudoaneurysm or arteriovenous fistula (AVF). Degree of ConfidenceThoracic angiography is both sensitive and specific for traumatic aortic injury. Injury to the subclavian artery may require selective injection of a contrast agent into the proximal subclavian artery to make the diagnosis of a traumatic pseudoaneurysm. The use of digital subtraction angiography (DSA) permits full evaluation of the injured artery without the artifacts that are caused by any superimposed bone. False Positives/NegativesThe failure to identify an arterial laceration or pseudoaneurysm is most commonly associated with motion artifacts, rotation, or poor angiographic technique. Ulcerated plaques within the aortic arch of older patients have been mistaken for aortic trauma. The origin of branch vessels that is otherwise poorly filled has been mistaken for small aneurysms. INTERVENTIONSection 10 of 13
Radiologic intervention Radiologic intervention in cases of rib trauma generally represents emergency treatment of the complications of chest-wall injuries (pneumothoraces) or the control of hemorrhage. Angiography may be used as a diagnostic technique in cases in which findings in the aortic arch and anterior mediastinum remain in doubt. Treatment Bansidhar et al found that 93% of patients with clinical rib fractures are able to resume their daily activities without disability.39 As a result, the authors did not recommend routine chest radiographic follow-up in addition to physical examination except in the presence of clinical deterioration. Adequate pain control, rapid mobilization, and meticulous respiratory care can prevent respiratory complications in patients with rib fractures. An adequate oral analgesic or an intercostal nerve block plus an oral analgesic should provide reasonable pain relief. Epidural analgesia is becoming the standard of care for pain management in patients with multiple rib fractures. In a study in which morphine patient-controlled analgesia (PCA) was compared with thoracic epidural analgesia involving bupivacaine and fentanyl, the latter provided more adequate pain control.16 In another study regarding the effectiveness of intrapleural analgesia for blunt trauma of the chest wall, this treatment did not significantly differ from placebo.15 Furthermore, the investigators did not recommend intrapleural analgesia for pain management in patients with rib fractures. Rapid mobilization can include oscillation therapy or body positioning in patients that are on bed rest or who are intubated. This mobilization can involve the patient's ambulating, sitting up in bed, or getting out of bed to move into a chair. Respiratory care entails incentive spirometry, pulmonary toilet, and even mechanical ventilation, when indicated. In splinting the rib fractures, adhesive strapping or chest binders should be avoided in all patients except the very young. Medical/Legal Pitfalls
Related eMedicine topics: ACKNOWLEDGMENTSSection 11 of 13
I would like to recognize the support provided by Ms. Dot Howard, RN, MSN, CEN, Trauma Manager, and the other members of the Trauma Program Staff of Methodist Dallas Medical Center, Dallas, Texas. MULTIMEDIASection 12 of 13
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