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PubMed1996

Rib fractures in major trauma.

BACKGROUND: To determine the mortality, hospital and intensive care unit (ICU) stay of rib fractures in patients admitted to Victorian hospitals for more than 1 day. METHODS: All patients fitting the entry criteria for the Victorian Major Trauma Study with fractured ribs were identified between 1 March 1992 and 28 February 1993. Aetiology, age, sex, associated injury and outcome were analysed. RESULTS: Patients with rib fractures had a higher mortality and length of hospital stay, but this was not significantly different from other trauma. A significantly higher percentage of patients required ICU care for rib fractures (44%) compared with the total group with blunt injury (24%). The majority of rib fractures resulted from motor vehicle accidents 361/541 (67%). Injuries occurring on the street/highway resulting in rib fractures were more likely to be major; 62% had Injury Severity Score (ISS) > 15. Fractured ribs occurred more commonly with increased age. Mortality for patients with fractured ribs versus total trauma group was higher in elderly patients. Univariate analysis showed rib fractures were a positive predictor of death but when adjusted for ISS and age, rib fractures became a negative predictor. Rib fractures were not predictors for length of ICU or hospital stay. CONCLUSION: The sample of rib fractures collected in this study underestimates the overall incidence. For those patients admitted to hospital with identified rib fractures, there is a trend towards higher mortality and morbidity. However, this association is better predicted by ISS and age.

Adolescent↗
PubMed2000

Cause and clinical characteristics of rib fractures in infants.

OBJECTIVE: Rib fractures are uncommon in infancy and, when diagnosed, often raise the suspicion of child abuse. However, the prevalence of other causes of rib fractures has not been well defined. The purpose of this study was to determine the causes and clinical presentations of rib fractures in infants <12 months old. METHODS: Retrospectively, we identified all infants with rib fractures under 12 months old over a 3-year period using computerized databases at the Children's Hospital Medical Center in Cincinnati, Ohio and at the Children's Hospital, Winnipeg, Manitoba, Canada. Data extracted from the individual patient charts included: age, sex, chief complaint, number and location of rib fractures, associated injuries, birth history, history of cardiopulmonary resuscitation, and any evidence of bone dysplasia. After the chart review and a review of the radiographs by a pediatric radiologist, all fractures were determined to be attributable to one of the following causes: child abuse, birth injury, bone fragility, or accidental trauma. A determination of abuse was made when there were other injuries indicative of abuse, there was no clinical or radiographic evidence of bone fragility, there was a confession of abuse, when no reasonable history of trauma was provided, or when the history was not plausible to explain the rib fractures. Standard practice at these hospitals involves obtaining skeletal surveys on all children <2 years old when abuse is suspected. The child abuse team, which consists of physicians, nurses, and social workers, conducts these investigations and works closely with police in evaluating these children. RESULTS: Thirty-nine infants with rib fractures were identified. Thirty-two (82%) were caused by child abuse. Three (7. 7%) were attributable to accidental injuries, 1 (2.6%) was secondary to birth trauma, and 3 (7.7%) were attributable to bone fragility. All 3 infants with fractures from accidental injury had sustained notable trauma (a motor vehicle collision, a forceful direct blow, and a fall from a height). Of the 3 infants with fractures secondary to bone fragility, 1 infant had osteogenesis imperfecta, 1 infant had rickets, and 1 infant, who was born at 23 weeks' gestation, had fragile bones attributable to prematurity. CONCLUSIONS: Most rib fractures in infants are caused by child abuse. Although much less common, rib fractures can also occur after serious accidental injuries, birth trauma, or secondary to bone fragility. A thorough clinical and imaging evaluation is mandatory.

Birth Injuries↗
PubMed1985

The significance of first and second rib fractures.

There are differing opinions in the literature regarding the significance of first rib fractures. The plan at Westmead Centre is to standardize the initial assessment of patients with such fractures. A 3 year retrospective study of 170 trauma victims who sustained fractured ribs, was undertaken. Of the 15 patients with first rib fracture, all were involved in motor vehicle accidents. Over two-thirds of these patients sustained major chest injuries. Multisystem trauma involving cranial, abdominal or skeletal injury was common. One patient died as a result of head injury. Similar results were observed in 13 patients with second rib fractures. Brachial plexus injuries were noted in two patients with first rib fracture. Despite follow-up of high-risk patients at an interval which varied from 1 to 2 1/2 years after the original injury, major subclavian artery injury was not detected in patients with first rib fracture. From this experience and a literature review, we suggest that the general nature of trauma is similar in patients with first rib fracture to that in patients with second rib fracture. Patients with first rib fracture should be closely examined for neurovascular compromise. Guidelines for the use of angiography are discussed. If there is no evidence of neurovascular injury at presentation, and there is no other thoracic injury, recovery should be uneventful.

Adult↗
PubMed1994

The morbidity and mortality of rib fractures.

The incidence of rib fractures secondary to trauma has not been clearly reported. Of the 7147 patients seen by our trauma service from January 1987 to June 1992, 711 (10%) had rib fractures. Among the patients with rib fractures, 84 (12%) died, 670 (94%) had associated injuries, 274 (32%) had a hemothorax or pneumothorax, and 187 (26%) had a lung contusion. Fifty-five percent of the patients required an immediate operation or admission to the intensive care unit. Thirty-five percent of the patients required discharge to an extended care facility and 35% developed a pulmonary complication. We conclude that rib fractures are a marker of severe injury in which (1) 12% will die because of their injuries, (2) more than 90% will have associated injuries, (3) one half will require operative and ICU care, (4) one third will develop pulmonary complications, and (5) one third will require discharge to an extended care facility.

Adolescent↗
PubMed2003

A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management.

OBJECTIVE: A rib fracture secondary to blunt thoracic trauma is an important indicator of the severity of the trauma. In the present study we explored the morbidity and mortality rates and the management following rib fractures. METHODS: Between May 1999 and May 2001, 1417 cases who presented to our clinic for thoracic trauma were reviewed retrospectively. Five hundred and forty-eight (38.7%) of the cases had rib fracture. There were 331 males and 217 females, with an overall mean age of 43 years (range: 5-78 years). These patients were allocated into groups according to their ages, the number of fractured ribs and status, i.e. whether they were stable or unstable (flail chest). RESULTS: The etiology of the trauma included road traffic accidents in 330 cases, falls in 122, assault in 54, and industrial accidents in 42 cases. Pulmonary complications such as pneumothorax (37.2%), hemothorax (26.8%), hemo-pneumothorax (15.3%), pulmonary contusion (17.2%), flail chest (5.8%) and isolated subcutaneous emphysema (2.2%) were noted. 40.1% of the cases with rib fracture were treated in intensive care units. The mean duration of their stay in the intensive care unit was 11.8+/-6.2 days. 42.8% of the cases were treated in the wards whereby their mean duration of hospital stay was 4.5+/-3.4 days, while 17.1% of the cases were followed up in the outpatient clinic. Twenty-seven patients required surgery. Mortality rate was calculated as 5.7% (n=31). CONCLUSIONS: Rib fractures can be interpreted as signs of significant trauma. The greater the number of fractured ribs, the higher the mortality and morbidity rates. Patients with isolated rib fractures should be hospitalized if the number of fractured ribs is three or more. We also advocate that elderly patients with six or more fractured ribs should be treated in intensive care units due to high morbidity and mortality.

Accidental Falls↗
PubMed1991

Rib fractures in athletes.

Rib fractures are the most common serious injury of the chest. They occur most commonly in the middle and lower ribs with blunt trauma, and also with direct force to a small area of the chest wall and violent muscle contractions. Diagnosis is generally not difficult. The athlete should have a chest x-ray to confirm the diagnosis. Differential diagnosis includes severe rib contusion, costochondral separations, muscle strains and pneumothorax. If no internal problems exist, treatment consists of ice, NSAIDs, analgesics and a rib belt or tape. Healing should be well on its way before a return to sports. Fractures of the first 4 ribs or the last 2 ribs, multiple fractures and flail segments are less benign than other fractures, and may result in injury to surrounding structures. First rib and floating rib fractures are uniquely athletic fractures; they are avulsion fractures caused by a sudden vigorous contraction in different directions of pull.

Athletic Injuries↗
PubMed1994

[Disorders of respiratory function in rib fractures].

In the one-year prospective study 71 injured patients were observed (75% male and 25% female). Traffic traumatism was the dominant case (45%). The wounded are divided in the groups with one side fracture of ribs (left/right) and on both sides fracture of ribs considering the side of fracture, and there is consideration about the kind of fracture--there are single fracture of ribs and serial fracture of ribs. The samples of artery blood were followed in PaCO2, %SaO2 and level pH in three points of time: when the patients came, after 24 and after 48 hours. In the group with the both side fracture of the ribs, the fall of worth pH was observed after 48 hours, PaCO2 is increasing to the 6.98 kPa. PaO2 is falling after 48 hours. In %SaO2 there is no considerable difference at any time, but%SaO2 is the highest in the second group. With the serial fracture of ribs wounded are considerate the fall of worth pH which is progressively increasing and is the highest after 48 hours. PaCO2 is increasing in the both groups, but with the serial fracture the worth are considerably higher. PaO2 and %SaO2 are much lower after 48 hours. The authors conclude that the wounded on both sides and wounded with serial fracture along one or several lines of with fracture of all ribs suffer the highest respiratory insufficiency (ARI), so they need artificial ventilation as respiratory support.

Adult↗
PubMed2001

Two cases of isolated first rib fracture.

Isolated first rib fractures are uncommon. They are usually associated with severe blunt trauma, although other mechanisms have been suggested, these being (a) indirect trauma, (b) sudden contraction of the neck muscles, and (c) stress or fatigue fractures attributable to repeated pull of muscles. Two cases are reported of stress fracture of the first rib, who presented to the accident and emergency department.

Adolescent↗
PubMed1988

Factors affecting visualization of posterior rib fractures in abused infants.

Rib fractures frequently are encountered in abused infants and commonly occur in the posterior rib arcs. Fractures occurring near the costovertebral articulations are rarely identified radiographically in the acute phase, and callus formation usually is the first indication of injury. To assess the factors influencing the visibility of fractures near the costovertebral articulations in abused infants, 103 posterior rib fractures occurring in 16 abused infants were studied radiologically. The plain radiologic studies were correlated with the pathologic findings in 15 ribs from four patients. The limited visibility of fractures relates to (1) the frequent superimposition of the transverse process over the rib fracture site, (2) a fracture line that crosses at an obliquity to the radiographic beam, and (3) nondisplacement of rib fragments due to preservation of the posterior periosteum. Fresh fractures invisible on a frontal projection are clearly defined when the rib is viewed axially with postmortem radiography. These findings explain the reported superior sensitivity of radionuclide bone scans vs radiography in the identification of fresh posterior rib fractures. A knowledge of the factors influencing the visibility of these important injuries is useful in planning an appropriate diagnostic evaluation in cases of suspected infant abuse.

Child Abuse↗
PubMed1977

[Late sequelae of rib fractures].

For an assessment of the late lesions after rib fractures 108 patients having had an accident between 1968 and 1973 were followed up. As to the individual signs observed, the patients were very heterogeneous. Radiodiagnostic, spirometric and scintigraphic data were compiled in order to characterize the late morphologic and functional lesions. By means of correlation and discrimination analyses as well as tests of significance we found that the extension of the late lesions depends either on the age of the patient nor on the number of fractured ribs but, instead, on concomitant intrathoracic lesions. The late morphologic lesions such as deformedly healed rib fractures and pleural thickening were the substrate for the ventilative and circulatory disturbances of the lung.

Adult↗
PubMedDate not supplied

[The forensic medical classification of rib fractures].

Classification of rib fractures in thoracic blunt trauma is suggested. Classification accounts for environmental conditions, types of thoracic lesions as well as differential features of fractures. Systematization provides for single terminology to define fractures, it helps to determine mechanogenesis of thoracic trauma and may serve as the basis for compiling diagnostical computer program.

Forensic Medicine↗
PubMed2000

Rib fractures induced by coughing: an unusual cause of acute chest pain.

We report three patients with stress fractures of the ribs induced by coughing. Standard radiographs of the chest and ribs did not reveal evidence of rib fractures in any of the patients. Bone scintigraphy, performed 1 to 2 weeks after initial onset of symptoms, showed a focal area of increased uptake along the chest wall in all cases. Thin section angulated helical CT directly visualized the subtle rib fractures. Initial diagnosis of a cough-induced fracture of the rib may be difficult because of the associated underlying disorder, and unnecessary examinations are commonly performed. Identification of a cough-induced fracture of the rib using helical CT may be clinically important to avoid unnecessary concern and additional examinations.

Adult↗
PubMed2002

Epidural buprenorphine in management of pain in multiple rib fractures.

BACKGROUND: Pain from multiple rib fractures may affect pulmonary function, morbidity, and length of stay in the intensive care units. This study describes some clinical characteristics of epidural buprenorphine, a lipophilic and partial opiate agonist with a higher micro receptor affinity than morphine, in combating the pain in multiple rib fractures. METHODS: The study was conducted prospectively over a 15-month period. A total of 27 patients admitted to the hospital with multiple rib fractures were studied. Buprenorphine at a concentration of 0.3 mg in 5-10 ml normal saline was administered epidurally, twice daily the first 24 h, thereafter once daily. Ventilatory function tests (including vital capacity, tidal volume, respiratory rate, and minute volume) and assessment of pain intensity using a simple, categorical, verbal rating scale were obtained before and after institution of analgesia. Any nausea, vomiting, hypotension, urinary retention, respiratory depression or pruritus were recorded. RESULTS: We found a significant improvement in ventilatory function tests during the 1st, 2nd, and 3rd day after epidural analgesia when compared with the preanalgesia levels (P < 0.001). Changes in the verbal rating scale demonstrated that epidural buprenorphine was associated with marked improvement in pain at rest and pain during coughing and deep breathing. None of our patients developed hypotension (<10% of the baseline), urinary retention or respiratory depression. Nausea, vomiting, and mild pruritus were the only reported complications. CONCLUSIONS: Epidurally introduced narcotic, like buprenorphine in saline, has been found to be effective in our study to achieve adequate analgesia in treatment of patients with multiple rib fractures. In addition, this methodology of pain relief eliminates the costly delivery system and early discharge, and allows walking epidurals and follow-up on outpatient basis.

Analgesia, Epidural↗
PubMed1982

Severity of intrathoracic injuries associated with first rib fractures.

The benign condition of isolated first rib fracture is compared with the severity of intrathoracic injuries resulting from first rib fracture associated with multiple rib injuries. Seventy-five patients with 90 first rib fractures were divided into two groups. Group 1 (n = 13) included those with isolated first rib fractures and Group 2 (n = 62), those with first-rib fractures associated with multiple rib injuries. In Group 1 patients, intrathoracic injuries were mild with no major vascular injuries. Conversely, Group 2 patients sustained severe intrathoracic injury, 58% of them with aortic injury. Stress is placed on early diagnosis, assigning of priority to associated injuries, and early operative intervention.

Accidents, Home↗
PubMed1990

Rib fracture due to bench pressing.

Rib fractures are commonly associated with blunt trauma, but there are instances where this is not the case. In this case a patient fractured the second rib during a "bench press" weight lifting maneuver. The possible etiology is proposed, and the incidence, causes, diagnosis, complications, and treatment of rib fractures are discussed.

Adult↗
PubMed2006

Adverse outcomes in younger rib fracture patients.

BACKGROUND: Recent studies on the impact of rib fractures after blunt trauma have shown a linear relationship between age, increasing number of rib fractures, and complications, including mortality. Others have documented that age-related morbidity increases before age 65 in trauma patients. We hypothesize that patients as young as age 45 demonstrate increased morbidity with injuries similar to older patients. METHODS: We performed a retrospective cohort study involving all blunt trauma patients with rib fractures, excluding those with severe head and abdominal injuries and those dying within 24 hours, admitted between January 2001 and December 2004. Outcome parameters included pulmonary complications, ICU length of stay, hospital and ICU length of stay, Injury Severity Score (ISS), number of vent days, number of rib fractures, mechanism of injury, and discharge disposition. RESULTS: Of the 3,094 patients admitted, 307 met the inclusion criteria (9.9%). Based on statistical analysis of age, number of rib fractures, and adverse outcome variables, patients were separated into 4 groups: Group 1: younger than 44 years old with 1 to 4 rib fractures, Group 2: younger than 44 years with greater than 4 rib fractures, Group 3: 45 years or older with 1 to 4 rib fractures, and Group 4: 45 years or older with more than 4 rib fractures. Age groups and outcome variables were compared with chi-square, analysis of variance and multiple regression analysis. Respiratory failure, pneumonia, and associated thoracic injuries were increased in Group 4 patients compared with other groups (P < 0.05). Mortality and length of stay were not different between groups. CONCLUSIONS: Patients as young as 45 with more than 4 rib fractures are at increased risk for adverse outcomes. Efforts to improve outcomes in rib fracture patients should focus not only on elderly patients, but on those as young as 45 years. Based on these data, we established a rib fracture clinical pathway focusing on patients 45 years and older with more than 4 rib fractures.

Adolescent↗