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PubMed1983

Upper rib fractures and mediastinal widening: indications for aortography.

Survival of patients with posttraumatic thoracic aortic rupture depends on early diagnosis. It is frequently stated that fracture of the first or second ribs and mediastinal widening are findings suggestive of thoracic aortic rupture. We found that the probability of sustaining thoracic aortic rupture is the same for patients with upper rib fractures as for those with other rib fractures (1/64 versus 5/149; p = 0.85). Also, our data fail to show a statistical difference in the incidence of thoracic aortic rupture associated with upper (first and second) rib fractures compared with no rib fracture at all (1/64 versus 9/304; p = 0.85). Thus, patients with thoracic aortic rupture are not more likely to have rib fractures (7/21 versus 14/21; p = 0.15), and if a rib fracture is present, the probability of it being at the upper level is the same as that for a fracture at any other level (1/7 versus 6/7; p = 0.06). Ratios of mediastinal width to chest width were used as a measure of mediastinal widening, and were found to be an accurate predictor of thoracic aortic rupture. Ratios greater than 0.28 at the aortic knob were 100% specific and 85% sensitive for this condition.

Aorta, Thoracic↗
PubMed1991

[Intrapleural catheter analgesia in patients with multiple rib fractures].

Patients with multiple rib fractures often suffer from severe pain that impairs their respiratory performance. The effect of interpleural administration of bupivacaine (20 ml 0.25% every 4 h) for pain management was evaluated in ten patients. The initial interpleural injection resulted in significant pain relief and improvement of arterial oxygen tension. Two patients needed additional i.v. injections of opioids (piritramide 15-22.5 mg/24 h). In one patient a small asymptomatic pneumothorax was observed following placement of the catheter, which resolved spontaneously. No other complications were reported. In an intraindividual comparison, bupivacaine alone and bupivacaine plus epinephrine 1:200,000 were compared with regard to pharmacokinetics of bupivacaine, analgesic effect, side effects, and respiratory performance. The addition of epinephrine yielded only minor advantages from a pharmacokinetic point of view (median peak concentration of bupivacaine 1.8 micrograms/ml vs 2.0 micrograms/ml for bupivacaine alone). The quality and duration of analgesia and the effects on respiration were not influenced by epinephrine. The heart rate was significantly higher and the blood pressure significantly lower when epinephrine was added to the solution. Nevertheless, these differences were too small to be of clinical importance. Even though maximum total plasma concentrations of bupivacaine above 2 micrograms/ml were found in some patients, there were no signs of CNS toxicity, most probably because of the increased protein binding of bupivacaine following trauma. Accordingly, the maximum free plasma concentrations in all patients were below the threshold level of 0.24 micron/ml. We therefore conclude tht interpleural administration of bupivacaine could be a valuable means of pain relief in patients with multiple rib fractures, providing no severe pulmonary contusions or concomitant injuries are present.

Adult↗
PubMed1998

Traumatic thoracic aortic injury caused by a sharp edge of left fractured rib on body position change: case report.

Aortic injury caused by penetration of a fractured rib is very rare. We present a patient with aortic injury demonstrated using serial imaging studies. A 66-year-old woman fell from a ladder and sustained multiple left-side rib fractures. There was a small left hemothorax and widened mediastinum on the initial chest roentgenogram in the emergency department. Chest computed tomography (CT) revealed a posterior segmental fracture of the sixth rib on the left side with a sharp edge penetrating into the posterior aspect of the thoracic aorta. It was initially missed. More than 1000 cc of fresh blood suddenly gushed out of the chest tube 7 hours after the traumatic event. After resuscitation, an aortogram was performed which showed blood extravasation from the thoracic aorta at the rib fracture site. Unfortunately, surgical intervention was delayed and she died. Early detection and early surgical intervention are necessary in patients with a widened mediastinum and positive results on imaging studies.

Aged↗
PubMed2005

Rib fractures predict incident limb fractures: results from the European prospective osteoporosis study.

Population studies suggest that rib fractures are associated with a reduction in bone mass. While much is known about the predictive risk of hip, spine and distal forearm fracture on the risk of future fracture, little is known about the impact of rib fracture. The aim of this study was to determine whether a recalled history of rib fracture was associated with an increased risk of future limb fracture. Men and women aged 50 years and over were recruited from population registers in 31 European centres for participation in a screening survey of osteoporosis (European Prospective Osteoporosis Study). Subjects were invited to complete an interviewer-administered questionnaire that included questions about previous fractures including rib fracture, the age of their first fracture and also the level of trauma. Lateral spine radiographs were performed and the presence of vertebral deformity was determined morphometrically. Following the baseline survey, subjects were followed prospectively by annual postal questionnaire to determine the occurrence of clinical fractures. The subjects included 6,344 men, with a mean age of 64.2 years, and 6,788 women, with a mean age of 63.6 years, who were followed for a median of 3 years (range 0.4-5.9 years), of whom 135 men (2.3%) and 101 women (1.6%) reported a previous low trauma rib fracture. In total, 138 men and 391 women sustained a limb fracture during follow-up. In women, after age adjustment, those with a recalled history of low trauma rib fracture had an increased risk of sustaining 'any' limb fracture [relative hazard (RH)=2.3; 95% CI 1.3, 4.0]. When stratified by fracture type the predictive risk was more marked for hip (RH=7.7; 95% CI 2.3, 25.9) and humerus fracture (RH=4.5; 95% CI 1.4, 14.6) than other sites (RH=1.6; 95% CI 0.6, 4.3). Additional adjustment for prevalent vertebral deformity and previous (non-rib) low trauma fractures at other sites slightly reduced the strength of the association between rib fracture and subsequent limb fracture. In men, after age adjustment, there was a small though non-significant association between recalled history of rib fracture and future limb fracture. Our data highlight the importance of rib fracture as a marker of bone fragility in women.

Aged↗
PubMed1998

[Surgical stabilization of multiple rib fractures successfully achieved with the use of long metalic plates].

Surgical stabilization of multiple rib fractures in 5 male patients was successfully achieved with the use of orthopedic A-O metalic plates, which are called reconstruction plates. In each patient, we prevented deformity of the rib cage and flail chest which frequently occurs after multiple rib fractures. Three of these patients received emergency operations because of severe hemopneumothorax and flail chest due to crushing injuries to the chest. They were treated by the standard thoracotomy, hemostasis of intrapleural bleeding, and stabilization of fractured ribs with reconstruction plates, in addition two of the patients underwent a single lobectomy to control the pulmonary hemorrhage. Another two patients were treated with mechanical ventilation and closed-tube thoracotomy following the chest trauma because their thoracic bleeding from drainage tubes was tolerable. But flail chest and respiratory insufficiency did not improve, in spite of positive controlled ventilation as a mode of internal pneumatic stabilization. Then surgical stabilization of the fractured ribs with these plates was carried out ten to twelve days after the accidents in each case. All patients tolerated the surgical procedures well and were successfully removed from the respirator, demonstrating complete stability of the chest wall. The long metal reconstruction plates with many perforations were very useful for the external fixation of segmentary fractured ribs as an external brace. This was because they were long enough to cover the whole length of the fractured ribs and moderately soft enough to be appropriately bent or twisted by hand at the time of operation. Moreover a number of holes in it allowed the suture to pass through the plate and rib, avoiding displacement of the prosthesis. This is the first report which describes the usefulness of orthopedic reconstruction plates for the stabilization of multiple rib fractures.

Adult↗
PubMed2005

Cough-induced rib fractures.

OBJECTIVES: To define the demographic, clinical, and radiological features of patients with cough-induced rib fractures and to assess potential risk factors. PATIENTS AND METHODS: For this retrospective, single-center study, we identified all cases of cough-induced rib fractures diagnosed at the Mayo Clinic in Rochester, Minn, over a 9-year period between January 1, 1996, and January 31, 2005. Bone densitometry data from patients' medical records were analyzed, and T scores were used to classify patients into bone density categories. RESULTS: The mean +/- SD age of the 54 study patients at presentation was 55+/-17 years, and 42 patients (78%) were female. Patients presented with chest wall pain after onset of cough. Rib fracture was associated with chronic cough (> or =3 weeks' duration) in 85% of patients. Rib fractures were documented by chest radiography, rib radiography, computed tomography, or bone scan. Chest radiography had been performed in 52 patients and revealed rib fracture in 30 (58%). There were 112 fractured ribs in 54 patients. One half of patients had more than one fractured rib. Right-sided rib fractures alone were present in 17 patients (26 fractured ribs), left-sided in 23 patients (35 fractured ribs), and bilateral in 14 patients (51 fractured ribs). The most commonly fractured rib on both sides was rib 6. The fractures were most common at the lateral aspect of the rib cage. Bone densitometry was done in 26 patients and revealed osteopenia or osteoporosis in 17 (65%). CONCLUSIONS: Cough-induced rib fractures occur primarily in women with chronic cough. Middle ribs along the lateral aspect of the rib cage are affected most commonly. Although reduced bone density is likely a risk factor, cough-induced rib fractures can occur in the presence of normal bone density.

Adult↗
PubMed1998

Isolated bilateral first rib fractures--an unusual sequel of whiplash injury.

Fractures of the first rib are extremely rare and are more commonly associated with either multiple rib fractures or life-threatening injuries. First rib fractures are commonly caused by direct trauma, violent muscular contraction or by chronic stress. We present a case of isolated bilateral rib fracture in an elderly patient, in the absence of multiple trauma, where the mechanism of injury appears to be a whiplash injury.

Accidents, Traffic↗
PubMed1989

Use of rib belts in acute rib fractures.

The current treatment for uncomplicated rib fractures is the exclusion of associated injuries followed by symptomatic treatment with analgesics. Encouragement of deep breathing is also recommended to avoid secondary or delayed pulmonary complications. The use of circumferential rib belts in treating patients with acute rib fractures has been discouraged because of possible complications from restricted ventilation. A review of the literature revealed no previous clinical studies to support this view. We designed and conducted a controlled, prospective, randomized pilot study to determine if there was any increased morbidity associated with the use of rib belts in the treatment of patients with acute rib fractures. Twenty-five adult patients with radiographically proven acute rib fractures were randomized into two groups. The first group was treated with analgesics and a standard circumferential rib belt (Zimmer Universal Rib Belt). The second group was treated with oral analgesics alone. Patients were contacted by telephone three days after the initial injury and then reexamined 14 days postinjury. Rates of pain resolution, compliance, and delayed complications were determined. Rib belts were not found to significantly reduce the severity of pain. Four complications (one case of bloody pleural effusion requiring hospitalization, two cases of asymptomatic discoid atelectasis, and one case of allergic contact dermatitis) were identified, all occurring in the group of patients receiving rib belts. This pilot study indicates that while rib belts are widely accepted by patients for control of pain, they appear to be associated with an increased incidence of complications. Clinical studies with larger sample sizes will be needed to confirm these findings.

Acetaminophen↗
PubMed2002

[Arterial vascular injury of the diaphragm caused by serial rib fracture].

About 10% of all trauma patients sustain rib fractures. The average age is 58. Men are more often affected than women. Hemothorax, pneumothorax, and lesions of the lung are not uncommon. Very rare are injuries of the pericardium, aorta, and subclavia caused by fractured ribs. We present a very unusual case where a broken rib caused a severe diaphragmatic hemorrhage with a hemothorax and acute hypovolemia. The primary chest X-ray was thought to be without pathology. Arterial bleeding without exact localization could be found with computed tomography. Thoracotomy revealed the correct diagnosis and the cause of bleeding.

Aged↗
PubMed1991

[Significance of rib fractures in simple and multiple trauma].

In a retrospect study we evaluated the clinical impact of traumatic rib fractures. Our series included 96 patients treated between 1986 and 1988. Haemato- and/or pneumothorax corresponded closely to the number of fractured ribs. There was a highly significant association (p less than 0.001) between the number of fractured ribs and polytrauma. The leading cause of injuries was a traffic accident.

Adult↗
PubMed2003

Disclosure of unnoticed rib fractures with the use of ultrasonography in minor blunt chest trauma.

OBJECTIVE: Rib fractures are the most common injuries resulting from blunt chest trauma. The sensitivity of chest X-rays in showing the rib fractures is limited particularly in those involving the cartilage part of the rib. We investigated the possible rib fractures, those overlooked on chest X-rays, with the use of ultrasonography in minor blunt chest trauma. METHODS: A total of 37 patients, with minor blunt chest trauma showing no evidence of a rib fracture on chest X-rays, were examined with ultrasonography performed with a 7.5-MHz linear transducer. Logistic regression analysis was done to outline the clinical predictors of these insidious rib fractures. RESULTS: A total of 15 (40.5%) patients showed rib lesions, whereas 22 (59.5%) patients had no evidence of rib lesions. Fracture of the rib associated with a subperiosteal hematoma was the most common finding in ten (66.7%) patients followed by the fracture of the rib alone in four (26.7%) patients, and subperiosteal hematoma alone in one (6.7%) patient. A total of eight (53.3%) patients had bony rib fractures, whereas seven (46.7%) patients had chondral rib fractures. Age (P=0.617), gender (P=0.552), type of etiology (P=0.954), duration of pain (P=0.234) and site of trauma (P=0.740) did not appear as significant predictors for these rib fractures. However, the involved part of the rib showed a significant correlation with either age (P=0.042) or duration of pain (P=0.033). Bony rib fractures significantly occurred in elderly patients, and the duration of pain in patients with bony rib fractures was significantly longer than that of patients with chondral rib fractures. CONCLUSIONS: Ultrasonography is a useful imaging method in showing the rib fractures those overlooked on chest X-rays in minor blunt chest trauma, and no significant clinical feature exists as a predictor for these insidious fractures. However, bony rib fractures significantly occur in elderly patients and result in a longer duration of pain.

Adolescent↗
PubMed2003

The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children.

BACKGROUND: Rib fractures have a strong association with nonaccidental trauma (NAT) and severe trauma. The purposes of this study were to evaluate rib fractures in children to determine (1) the positive predictive value of a rib fracture in defining NAT and (2) the frequency of rib fractures as the only skeletal manifestation of NAT. METHODS: We reviewed the medical records and imaging of all children with rib fractures over a 6-year period. NAT was determined by the Child Advocacy and Protection team. RESULTS: In children younger than 3 years of age, the positive predictive value (PPV) of a rib fracture as an indicator of NAT was 95%. The positive predictive value increased to 100% once historical and clinical circumstance excluded all other causes for rib fractures. CONCLUSION: In this study, rib fracture(s) were the only skeletal manifestation of NAT in 29% of the children.

Adolescent↗
PubMed2001

Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients.

BACKGROUND: Despite the lack of evidence, traditional trauma teaching has suggested that low rib fractures increase the risk of abdominal solid organ injury (ASOI). This study was designed to assess if in fact this is true, and to try and define other factors that increased the risk of ASOI in rib fracture patients. METHODS: The charts of 476 hospitalized rib fracture trauma patients were reviewed. Data were collected for age; sex; Injury Severity Score (ISS); rib fracture location; and the presence or absence of injuries to the abdominal organs, head, neck, face, thorax, great vessel, heart, thoracolumbar spine, pelvis, and extremities. RESULTS: The probability of liver injury increased with the presence of any right-sided rib fracture, any low rib fracture, female gender, young age, and an elevated ISS. The probability of splenic injury increased with the presence of left-sided rib fractures only, any low rib fracture, young age, and an elevated ISS. CONCLUSION: In hospitalized trauma patients, low rib fractures, right-sided rib fractures, female gender, young age, and an elevated ISS increased the probability of liver injury; and low rib fractures, left-sided only rib fractures, young age, and an elevated ISS increased the probability of splenic injury. Associated pelvic fractures and long bone fractures did not increase the likelihood of ASOI in this cohort.

Abdominal Injuries↗
PubMed1995

[Ultrasound detection of rib fractures for verifying fracture diagnosis. A pilot project].

Since the diagnosis of rib fractures caused by blunt thoracic trauma is often missed on X-ray, attempt have been made to detect unknown fractures with ultrasound. Ultrasound was initially researched, as a diagnostic technique in a preliminary study of 10 patients with known rib fractures. Subsequently, in the main study, 21 patients with clinically suspected rib fractures but normal thoracic X-rays were examined with ultrasound, and rib fractures were detected in 16 patients. The diagnosis of rib fractures by ultrasound was substantiated by an increase of activity in the technetium scintigram in 11 of 11 patients. We found further increases of activity in the scintigram in two more ribs in 7 of these 11 patients. This finding is explained by the presence of nondislocated rib fractures that are veiled to ultrasound when a disconnection of the rib's contour is missed during respiration. The diagnostic procedure is explained with reference to case studies. In summary, findings recorded in this study showed that ultrasound investigation is a more reliable method of diagnosis than X-rays examination.

Accidents, Traffic↗
PubMed2003

Morbidity from rib fractures increases after age 45.

BACKGROUND: Recent studies have demonstrated increased morbidity in elderly patients with rib fractures after blunt trauma. As a first step in creating a multidisciplinary rib fracture clinical pathway, we sought to determine the relationship between increasing age, number of rib fractures, and adverse outcomes in blunt chest trauma patients, without major abdominal or brain injury. STUDY DESIGN: We performed a retrospective cohort study involving all blunt patients greater than 15 years old with rib fractures, excluding those with Abbreviated Injury Scores (AIS) greater than 2 for abdomen and head, admitted to an urban Level I trauma center during 20 months. Outcomes parameters included the number of rib fractures, Injury Severity Score (ISS), intrathoracic injuries, pulmonary complications, number of ventilator days, length of stay in the intensive care unit (ICU), hospital stay, and type of analgesia. RESULTS: Of the 6,096 patients admitted, 171 (2.8%) met the inclusion criteria. Based on an analysis of increasing age, number of rib fractures, and adverse outcomes variables, patients were separated into four groups: group 1, 15 to 44 years old with 1 to 4 rib fractures; group 2, 15 to 44 years old with more than 4 rib fractures; group 3, 45 years or older with 1 to 4 rib fractures; and group 4, 45 years or more with more than 4 rib fractures. The four groups had similar numbers of pulmonary contusions (30%) and incidence of hemopneumothorax (51%). Ventilator days (5.8 +/- 1.8), ICU days (7.5 +/- 1.8), and total hospital stay (14.0 +/- 2.2) were increased in group 4 patients compared with the other groups (p < 0.05). Epidural analgesia did not affect outcomes. Overall mortality was 2.9% and was not different between groups. CONCLUSIONS: Patients over the age of 45 with more than four rib fractures are more severely injured and at increased risk of adverse outcomes. Efforts to decrease rib fracture morbidity should focus not only on elderly patients but those as young as 45 years. Based on these data we have initiated a multidisciplinary clinical pathway focusing on patients 45 years and older who have more than four rib fractures.

Adolescent↗