Rib Fractures

Epidemiology

General Demographics

  • Rib Fractures are Present in 10% of All Trauma Patients (Eur J Cardiothorac Surg, 2003) [MEDLINE]
    • Rib Fractures are Present in 30% of Trauma Patients with Significant Chest Trauma
    • The Number of Fractured Ribs Correlates with the Extent of Intrathoracic Injury

Demographic Data for Flail Chest

  • Flail Chest Occurred in 5-13% of Patients with Chest Wall Injury (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
  • Flail Chest Occurred in 1% of All Patients Admitted to Level ½ Trauma Centers (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
  • Mean Age: 52.5 yrs (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
  • Male Sex-Predominance: 77% of flail chest cases were male (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
  • Concomitant Injuries
    • Approximately 15% of Flail Chest Cases Had Coexisting Head Injury (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
    • Approximately 54% of Cases Had Coexisting Lung Contusion (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]

Etiology


Physiology

Flail Chest (“Stoved-In Chest”, Crushed Chest)

  • Definition: fractures of ≥3 Ribs in Two or More Locations on the Rib, Which Creates a Floating Segment of the Chest Wall
    • Floating Segment of Chest Wall Paradoxically Moves Inward on Inspiration (and Outward on Expiration)
      • This Paradoxical Inward Movement of the Chest Wall Segment on Inspiration Increases the Work of Breathing
  • Mechanism
    • Flail Chest is Most Commonly Due to Blunt Chest Wall Trauma with Significant Force Applied to the Chest: for this reason, pulmonary contusion occurs more commonly with rib fractures with flail chest, than with rib fractures without flail chest (Int Surg, 2002) [MEDLINE]
      • Assault with Blunt Object (Baseball Bat, etc)
      • Ejection from Vehicle/Motorcycle
      • Fall from Height with Chest Trauma
      • Motor Vehicle Accident with Chest Striking the Steering Wheel (with Front Impact) or Door (with Side Impact)
      • Motor Vehicle vs Cyclist/Pedestrian Injury
      • Shotgun Blast: less commonly-reported mechanism of flail chest

Sternal Flail

  • Definition: disconnection of the sternum from the hemithoraces due to bilateral, multiple anterior cartilage or rib fractures
    • Sternal Fracture May Coexist with Rib Fractures

Diagnosis

Chest X-Ray (see Chest X-Ray, Chest X-Ray)

  • xxx

Chest CT (see Chest Computed Tomography, Chest Computed Tomography)

  • xxxx

Thoracic Ultrasound (see Thoracic Ultrasound, Thoracic Ultrasound)

  • xxx

Clinical Manifestations

Pulmonary Manifestations

  • Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome, Acute Respiratory Distress Syndrome)
    • Epidemiology
      • ARDS Cccurred in 14% of Flail Chest Cases (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
  • Acute Respiratory Failure (see Respiratory Failure, Respiratory Failure)
    • Epidemiology
      • Respiratory Failure Requiring Mechanical Ventilation was Required in 59% of Flail Chest Cases (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]: mean duration of mechanical ventilation was 12.1 days
    • Physiology: due pain and loss of chest wall function (and associated pneumonia)
  • Chest Pain (see Chest Pain, Chest Pain)
    • Epidemiology: common
  • Dyspnea (see Dyspnea, Dyspnea)
    • Epidemiology: common
  • Empyema (see Pleural Effusion-Parapneumonic, Pleural Effusion-Parapneumonic)
    • Physiology: due to retained hemothorax, pneumonia, etc
  • Physical Exam Findings
    • Clicking Sensation with Deep Inspiration/Coughing/Valsalva Maneuver
    • Crepitus
    • Findings Related to Pleural Effusion/Pneumothorax (When They Coexist)
    • Flail Chest
      • Paradoxical Inward Movement of Region of the Chest Wall During Inspiration and/or Paradoxical Outward Movement of Region of the Chest During Expiration
      • Flail Chest Can Be Missed Early in the Course Due to Muscle Splinting with Concealment of the Floating Chest Wall Segment or Due to Early Intubation with Mechanical Ventilation (Under Positive Pressure)
    • Pain on Palpation
    • “Step-Off” on Rib
    • Visible Chest Wall Deformity
  • Pneumonia (see xxxx, xxxx)
    • Epidemiology
      • Pneumonia is the Most Common Complication of Rib Fractures
      • Pneumonia Occurred in 21% of Flail Chest Cases (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
      • Risk of Pneumonia is Associated with the Number of Rib Fractures
      • Risk of Pneumonia in the Setting of Rib Fractures is Further Increased with Older Age (J Trauma, 2000) [MEDLINE] and (J Trauma, 2003) [MEDLINE]
    • Physiology: due pain and loss of chest wall function
  • Sepsis (see Sepsis, Sepsis)
    • Epidemiology: sepsis occurred in 7% of flail chest cases (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]

Concomitant Traumatic Injuries

  • Hemothorax (see Pleural Effusion-Hemothorax, Pleural Effusion-Hemothorax)
    • May Be Delayed in Onset in Some Cases
    • Retained Hemothorax Increases the Risk of Empyema
  • Pneumothorax (see Pneumothorax, Pneumothorax)
    • Pneumothorax Occurs in 25% of Patients with Multiple Rib Fractures (Eur J Cardiothorac Surg, 2003) [MEDLINE]
    • May Be Delayed in Onset in Some Cases
  • Pulmonary Contusion (see Pulmonary Contusion, Pulmonary Contusion)
    • Pulmonary Contusion Occurs More Commonly with Rib fractures with Flail Chest than with Rib fractures without Flail Chest (Int Surg, 2002) [MEDLINE]
  • Sternal Fracture
    • Presence of Sternal Fracture Should Raise the Concern for Blunt Cardiac Injury

Long-Term Complications

  • Chronic Rib/Chest Wall Pain
  • Long-Term Disability
  • Rib Fracture Non-Union
    • Epidemiology: small percentage of rib fractures do not heal, despite formation of a fibrous capsule around the fracture site (“pseudoarthrosis”)

Treatment

Triage/Need for Hospitalization

Background

  • Number of Rib Fractures is Correlated with Morbidity/Mortality (Eur J Cardiothorac Surg, 2003) [MEDLINE] and (Crit Care Med, 2006) [MEDLINE]
  • Approximately 82% of Flail Chest Cases Required ICU Admission (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]

Recommendations

  • Isolated Traumatic Fracture of 1-2 Ribs: outpatient management with oral analgesics is recommended
  • Traumatic Fractures of ≥3 Ribs: hospitalization or transfer to regional trauma center is recommended
  • Patient >65 y/o with Rib Fractures: hospitalization should be considered due to comorbidities and increased risk of complications

Pulmonary Toilet

Fluid Management

  • Judicious Intravenous Fluid Resuscitation is Crucial to Limit the Extent of Pulmonary Edema Which Occurs Due to Associated Pulmonary Contusion (see Pulmonary Contusion, Pulmonary Contusion)

Recommendations for Management of Pulmonary Contusion/Flail Chest (Eastern Association for the Surgery of Trauma, EAST, Practice Guideline) (J Trauma Acute Care Surg, 2012) [MEDLINE]

  • Fluid Resuscitation
    • Trauma Patients with Pulmonary Contusion/Flail Chest Should Not Be Excessively Fluid Restricted, But Should Be Resuscitated as Required with Isotonic Crystalloid or Colloid to Maintain Adequate Tissue Perfusion (Level 2 Recommendation)
      • Once Resuscitated, Unnecessary Fluid Administration Should Be Avoided
    • Pulmonary Artery Catheter May Be Useful to Avoid Fluid Overload During Resuscitation (Level 2 Recommendation)
    • Diuretics May Be Used in the Setting of Hydrostatic Fluid Overload (Elevated Pulmonary Capillary Wedge Pressure, etc)/Congestive Heart Failure if the Patient is Hemodynamically Stable (Level 3 Recommendation)

Analgesia

Non-Regional Analgesia

Regional Analgesia/Anesthesia Techniques

  • Epidural Analgesia/Anesthesia (see Epidural Anesthesia, Epidural Anesthesia)
    • In Patients with Multiple Rib Fractures, Epidural Anesthesia is Associated with Improved Analgesia, Decreased Duration of Mechanical Ventilation, and Decreased Incidence of Hospital-Acquired Pneumonia (in Most, But Not All, Trials)
    • Only 8% of Flail Chest Cases were Managed with Epidural Anesthesia (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
    • Systematic Review and Meta-Analysis of Epidural Anesthesia for Traumatic Rib Fractures (Can J Anaesth, 2009) [MEDLINE]
      • Epidural Anesthesia Had No Impact on Mortality Rate, ICU Length of Stay, or Hospital Length of Stay
      • Epidural Anesthesia (with Thoracic Epidural Analgesia and Local Anesthetics) May Decrease the Duration of Mechanical Ventilation
  • Intercostal Nerve Block: provides band-like anesthesia at a specific level (although blocks at multiple levels are usually required)
  • Intrapleural Anesthesia: infusion of local anesthetic directly into the pleural space
  • Paravertebral Anesthesia: regional unilateral anesthesia using local anesthetic (ropivacaine, etc)

Recommendations for Management of Pulmonary Contusion/Flail Chest (Eastern Association for the Surgery of Trauma, EAST, Practice Guideline) (J Trauma Acute Care Surg, 2012) [MEDLINE]

  • Analgesia
    • Optimal Analgesia and Aggressive Chest Physiotherapy Should Be Applied to Minimize the Likelihood of Respiratory Failure and Mechanical Ventilation (Level 2 Recommendation)
    • Epidural Anesthesia is the Preferred Method of Analgesia in Severe Flail Chest (Level 2 Recommendation)
    • Insufficient Evidence to Prove the Effectiveness of Paravertebral Anesthesia in Trauma Populations (Level 3 Recommendation)
      • Paravertebral Anesthesia May Be Equivalent to Epidural Anesthesia and May Be Considered in Some Cases When Epidural Anesthesia is Contraindicated

Recommendations for Blunt Thoracic Trauma (Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society) (J Trauma Acute Care Surg, 2016) [MEDLINE]

  • Epidural Analgesia is Conditionally Recommended Over Non-Regional Modalities of Pain Control (Intravenous or Enteral Opiates/Acetaminophen/NSAID’s) (Very Low Quality Evidence)
    • If Age/Number of Rib Fractures/Severity of Injury are Considered, Stronger Positive Magnitude of Effect May Be Observed for Certain Outcomes
  • Paravertebral Block Had Equivalent Analgesia to Epidural Analgesia (and Provided Significant Analgesia as Compared to Baseline)
    • Lack of Data Comparing Paravertebral Block to Non-Regional Modalities of Pain Control (Intravenous or Enteral Opiates/Acetaminophen/NSAID’s)
  • Inadequate Data Regarding Intrapleural Analgesia vs Non-Regional Analgesia in Blunt Thoracic Trauma
  • Multimodal Analgesia (Different Classes of Analgesics, Including Opiates/NSAID’s/Acetaminophen/Pregabalin/Gabapentin) is Conditionally Recommended in Blunt Thoracic Trauma (Very Low Quality Evidence)
  • Inadequate Data Regarding Intercostal Analgesia vs Non-Regional Analgesia in Blunt Thoracic Trauma

Venous Thromboembolism Prophylaxis

  • Recommended

Antibiotics

  • May Be Required in Cases with Penetrating Chest Trauma: antibiotics may limit complications associated with chest tube placement

Mechanical Ventilation

  • Epidemiology
    • Approximately 59% of Flail Chest Cases Required Mechanical Ventilation (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
      • Mean Duration of Mechanical Ventilation: 12.1 days
  • Physiology
    • xxxx

Recommendations for Management of Pulmonary Contusion/Flail Chest (Eastern Association for the Surgery of Trauma, EAST, Practice Guideline) (J Trauma Acute Care Surg, 2012) [MEDLINE]

  • Mechanical Ventilation
    • Obligatory Mechanical Ventilation in the Absence of Respiratory Failure Solely for the Purpose of Overcoming Chest Wall Instability Should Be Avoided (Level 2 Recommendation)
    • Trial of Non-Invasive Positive Pressure Ventilation Should Be Considered in Alert, Compliant Patients with Marginal Respiratory Status in Combination with Optimal Regional Anesthesia (Level 3 Recommendation)
    • Patients with Pulmonary Contusion/Flail Chest Requiring Mechanical Ventilation Should Be Supported Based on Institutional Practice and Extubated at the Earliest Possible Time (Level 2 Recommendation)
      • PEEP (or CPAP) Should Be Utilized During Mechanical Ventilation
    • Independent Lung Ventilation May Be Considered in Severe Unilateral Pulmonary Contusion When Shunt Cannot Be Otherwise Corrected (Due to Maldistribution of Ventilation) or When Crossover Bleeding is Problematic (Level 3 Recommendation)
    • High-Frequency Oscillation Ventilation Has Not Been Demonstrated to Improve Survival in Blunt Chest Trauma with Pulmonary Contusion, But May Improve Oxygenation in Some Cases When Other Modalities Have Failed (Level 3 Recommendation)
      • High-Frequency Oscillation Ventilation May Be Considered When Patient Fails Other Mechanical Ventilation Modes

Surgical Stabilization

  • Epidemiology
    • Over 99% of Flail Chest Cases were Managed Non-Operatively (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
  • Indications for Surgical Stabilization
    • Advancing Age
    • Failure to Wean from Mechanical Ventilation
    • Flail Segment with Chest Wall Deformity
    • Need for Mechanical Ventilation
  • Clinical Efficacy
    • Trial of Surgical Stabilization Using Internal Pneumatic Stabilization of Flail Chest (J Trauma, 2002) [MEDLINE]
      • Surgical Stabilization Using Judet Struts has Beneficial Effects with Respect to Less Ventilatory Support, Lower Incidence of Pneumonia, Shorter Trauma ICU Stay, and Decreased Medical Cost as Compared to Internal Fixation
    • Trial of Surgical vs Conservative Treatment of Flail Chest (Interact Cardiovasc Thorac Surg, 2005) [MEDLINE]
      • Surgical Group Had Stabilization of the Chest Wall in 85% of Cases, as Compared to Stabilization in 50% of Conservative Group Patients
      • Surgical Group Had Decreased Ventilator Requirement and Less Restrictive PFT’s at 2 Months

Recommendations for Management of Pulmonary Contusion/Flail Chest (Eastern Association for the Surgery of Trauma, EAST, Practice Guideline) (J Trauma Acute Care Surg, 2012) [MEDLINE]

  • Surgical Fixation
    • Surgical Fixation May Be Considered for Cases of Severe Flail Chest Failing to Wean from Mechanical Ventilation (or When Thoracotomy is Required for Other Reasons) (Level 3 Recommendation)
      • Unclear Which Subgroup of Flail Chest Patients Benefit from Early Prophylactic Fixation
    • Insufficient Evidence to Recommend Any Type of Proprietary Implant for Surgical Fixation of Rib Fractures (Level 3 Recommendation)
      • In Vitro Studies Suggest that Rib Plating or Wrapping Devices are Likely Superior to Intramedullary Wires

Recommendations for Blunt Thoracic Trauma (Eastern Association for the Surgery of Trauma) (J Trauma Acute Care Surg, 2017) [MEDLINE]

  • Flail Chest After Blunt Thoracic Trauma
    • Rib Open Reduction with Internal Fixation (ORIF) is Conditionally Recommended to Decrease Mortality Rate, Decrease the Duration of Mechanical Ventilation, Decrease ICU Length of Stay, Decrease Hospital Length of Stay, Decrease the Incidence of Pneumonia, and Decrease the Need for Tracheostomy
    • Effect of Rib Open Reduction with Internal Fixation (ORIF) is Unclear
  • Non-Flail Rib Fractures
    • No Recommendation Regarding Rib Open Reduction with Internal Fixation (ORIF)

Other

Recommendations for Management of Pulmonary Contusion/Flail Chest (Eastern Association for the Surgery of Trauma, EAST, Practice Guideline) (J Trauma Acute Care Surg, 2012) [MEDLINE]

  • Protocols
    • Self-Activating Multidisciplinary Protocols for the Treatment of Chest Wall Injuries May Improve Outcome and Should Be Considered (Level 3 Recommendation)
  • Other
    • Steroids Should Not Be Used to Treat Pulmonary Contusion (Level 2 Recommendation)

Prognosis

Prognosis is Related to Number of Rib Fractures

  • Number of Rib Fractures is Correlated with Morbidity/Mortality (Eur J Cardiothorac Surg, 2003) [MEDLINE] and (Crit Care Med, 2006) [MEDLINE]

Mortality Rate for Flail Chest

  • Mortality Rate: 16% (National Trauma Data Bank, 2012) (J Trauma Acute Care Surg, 2014) [MEDLINE]
    • Presence of Head Injury Increased the Rate of Mechanical Ventilation, Length of ICU Stay, and Worse Outcome

References

General

  • Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study. J Trauma. 1990;30(6):689 [MEDLINE]
  • The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975 [MEDLINE]
  • Rib fractures in the elderly. J Trauma. 2000;48(6):1040 [MEDLINE]
  • Influence of flail chest on outcome among patients with severe thoracic cage trauma. Int Surg. 2002;87(4):240 [MEDLINE]
  • A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003;24(1):133 [MEDLINE]
  • Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478 [MEDLINE]
  • Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003;23(3):374 [MEDLINE]
  • Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138(4):717 [MEDLINE]
  • Cough-induced rib fractures. Mayo Clin Proc. 2005;80(7):879 [MEDLINE]
  • Rib fractures: relationship with pneumonia and mortality. Crit Care Med. 2006;34(6):1642 [MEDLINE]
  • Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014 Feb;76(2):462-8 [MEDLINE]

Treatment

  • Surgical stabilization of internal pneumatic stabilization?  A prospective randomized study of management of severe flail chest patients.  J Trauma  2002;52:727–732; discussion 732 [MEDLINE]
  • Surgical versus conservative treatment of flail chest.  Evaluation of the pulmonary status.  Interact Cardiovasc Thorac Surg  2005;4:583–587 [MEDLINE]
  • Rib fracture repair: indications, technical issues, and future directions. World J Surg. 2009;33(1):14 [MEDLINE]
  • Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. 2009;56(3):230 [MEDLINE]
  • Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73(5 suppl 4):S351-S361 [MEDLINE]
  • Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg 2014;76(2):462-468 [MEDLINE]
  • Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936 [MEDLINE]
  • Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82(3):618 [MEDLINE]
  • Rib fracture fixation in the 65 years and older population: A paradigm shift in management strategy at a Level I trauma center. J Trauma and Acute Care Surg: 2017; 82(3): 524–527