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PubMed1985

Upper rib fractures following median sternotomy.

First and second rib fractures occurred in 11 (16%) of 69 patients undergoing median sternotomy. Although 6 patients had no symptoms related to the rib fractures, 5 patients had postoperative chest, shoulder, and arm pain suggestive of angina pectoris or postpericardiotomy syndrome. The correct diagnosis of pain related to postoperative upper rib fracture may be made by direct visualization of the fracture on supine anteroposterior radiographs, elicitation of pain by palpation of the rib or motion of the upper extremity, lack of response to nitroglycerin, and negative electrocardiogram and cardiac enzyme levels. Upper rib fractures following median sternotomy are usually radiographically detectable within the first three postoperative days. Placement of the Ankeney sternal retractor with the upper blade in a lower position (fourth intercostal space) may reduce the incidence of this postoperative complication.

Adult↗
PubMedDate not supplied

Multiple rib fracture in a neonatal foal using a nylon strand suture repair technique.

OBJECTIVES: To report rib fracture repair using the Securos Cranial Cruciate Ligament Repair System (SCCLRS; Securos Veterinary Orthopedics, Charlton, MA) in a neonatal foal. STUDY DESIGN: Case report. ANIMALS: A 1-day-old Standardbred foal with fracture of left ribs 2-9. METHODS: Four days after admission the foal was anesthetized and rib fractures were repaired using open reduction and the SCCLRS. RESULTS: Rib fractures were successfully stabilized and the foal was discharged 7 days postoperatively without further complications. CONCLUSIONS: The SCCLRS provided a straightforward, effective method of rib fracture repair in neonatal foals. CLINICAL RELEVANCE: Effective rib fracture repair in neonatal foals can be achieved with the SCCLRS.

Animals↗
PubMed1996

Rib fractures in 31 abused infants: postmortem radiologic-histopathologic study.

PURPOSE: To examine the morphologic alterations of fractures of the lateral and anterior rib arcs and costochondral junction (CCJ) to better understand the factors that influence radiographic visualization and to gain insight into the mechanism of injury in rib fractures of abused infants. MATERIALS AND METHODS: Thirty-one infants (average age, 3 months) who died with inflicted skeletal injuries were studied with high-detail, pre- or postmortem skeletal surveys, or both, and radiography of specimens, with histologic analysis. The distribution and number of fractures were determined for each technique, and dating was performed on the basis of radiographic and histologic criteria. The radiologic features were correlated with the pathologic findings in comparable histologic sections. RESULTS: Of 165 fractures, 84 (51%) involved the ribs. Only 30 rib fractures (36%) were visible with skeletal survey examination. Lateral and anterior arc fractures tended to impact along the inner cortex of the rib. CCJ fractures tended to involve the inner aspect of the osteochondral interface with an associated osseous fragment. CONCLUSION: Acute and healing rib fractures are common in infants who died with inflicted injury; detection is technique-dependent. Use of high-detail skeletal radiography to identify these injuries in live and deceased infants appears justified.

Autopsy↗
PubMed2000

Intrathoracic and concurrent orthopedic injury associated with traumatic rib fracture in cats: 75 cases (1980-1998).

OBJECTIVE: To characterize rib, intrathoracic, and concurrent orthopedic injuries, and prognosis associated with traumatic rib fracture in cats. DESIGN: Retrospective study. ANIMALS: 75 cats. PROCEDURE: Medical records from January 1980 to August 1998 were examined for cats with traumatic rib fracture. Signalment, cause of trauma, interval from trauma to evaluation at a veterinary teaching hospital, referral status and date, method of diagnosis, duration of hospitalization, number and location of rib fractures, presence of flail chest, costal cartilage involvement, intrathoracic and concurrent orthopedic injury, and clinical outcome were reviewed. RESULTS: Median age was 3 years. Twenty-five (58%) cats with reported cause of trauma were injured by interaction with another animal. Forty-seven (78%) cats that were treated survived. Cats that died had a median duration of hospitalization of < 1 day. Ten (13%) cats had flail chest. Sixty-five (87%) cats had intrathoracic injury (median, 2 injuries). Nine (100%) cats without detected intrathoracic injury that were treated survived. Thirty-five (47%) cats had concurrent orthopedic injury. Cats with flail chest, pleural effusion, or diaphragmatic hernia were significantly more likely to die than cats without each injury. CONCLUSIONS AND CLINICAL RELEVANCE: Traumatic rib fracture in cats is associated with intrathoracic and concurrent orthopedic injury. Aggressive treatment of cats with traumatic rib fracture is warranted, because the prognosis is generally favorable. Diagnosis and treatment of intrathoracic injury associated with traumatic rib fracture in cats should precede management of concurrent orthopedic injury.

Animals↗
PubMed2000

Rib fracture patterns and radiologic detection--a restraint-based comparison.

This paper presents a study of the rib fracture patterns generated in simulated frontal collisions and the visibility of the rib fractures on plain film radiographs. Using 29 cadaver subjects, rib fractures were identified on oblique, lateral, and anteroposterior chest films by five radiologists independently and were compared with fractures found during a detailed necropsy. Physical, geometric, and experimental factors demonstrated an influence on the ability of a radiologist to identify rib fractures on an x-ray. Specifically, the restraint system configuration, the total number of fractures, the circumferential location of the fracture, the rib number, and the aspect (right or left) affected fracture identification. The results verify that torso belt loading produces rib fractures generally located along the path of the belt whereas superimposed airbag loading results in a more distributed and posterolateral fracture pattern. A higher proportion of rib fractures was identified on x-ray for occupants restrained by only a belt (44% of fractures) than for occupants restrained by both a belt and an airbag (24% of fractures). Overall, less than 40% of the rib fractures were detected upon an initial examination of radiographs. After being provided with the location of all fractures, detection increased to 49%. On average, occult rib fractures resulted in an average underreporting of injury severity of more than one AIS level.

Acceleration↗
PubMed1999

Is there an association between fractures of the cervical spine and first- and second-rib fractures?

OBJECTIVE: To investigate a potential association between cervical spine injury and first- and second-rib fractures. METHODS: Retrospective review of the radiologic and medical records of 28 consecutive patients admitted to an acute spinal injury unit. RESULTS: A total of 10 (36%) of the patients with cervical spine trauma also had fractures of either the first or second ribs. Eight of these 10 patients had a fracture or fracture-subluxation of the seventh cervical vertebra or the C6/7 segment. CONCLUSION: Almost one-third of patients with traumatic cervical spine injury have an associated upper-rib fracture. The strongest association is between injury at the C7 level and first-rib fracture.

Adolescent↗
PubMed1995

Extrapleural bupivacaine for amelioration of multiple rib fracture pain.

OBJECTIVE: The pain associated with multiple rib fractures can be surprisingly variable. The objective of this study was to determine the efficacy of an indwelling, percutaneously placed intercostal catheter in relieving the pain associated with multiple rib fractures. DESIGN: Prospective nonrandomized study setting: Surgical intensive care unit in a level 1 trauma center. SUBJECTS: Fifteen blunt chest trauma patients with a minimum of three rib fractures who had failed an intravenous patient controlled analgesia protocol. INTERVENTIONS: Insertion of an epidural catheter within the intercostal space. Bupivacaine 0.25% with epinephrine was injected in a volume of 20 mL. Subsequent doses were limited to a total of 400 mg per 24 hours. MEASUREMENTS AND MAIN RESULTS: Severity of injury was estimated by using the Injury Severity Score. For each patient a preinjection visual analogue scale (VAS) and incentive spirometry (IS) lung volume were determined. Fifteen minutes following injection of 0.25% bupivacaine with epinephrine the VAS and IS were repeated. The Injury Severity Score ranged from 9 to 32 (mean 19.0 +/- 1.6). Overall, mean VAS pain scores improved significantly following the initial bolus of bupivacaine (before VAS = 7.5 +/- 0.6, after VAS = 3.5 +/- 0.5, p < 0.05) and this was associated with significant increase in IS lung volumes (before IS = 0.77 +/- 0.09, after IS = 1.3 +/- 0.13, p < 0.05). No patient experienced either insertion-related or drug administration complications. CONCLUSIONS: These results confirm that an indwelling intercostal catheter provides a continuous nerve block resulting in a simple, safe procedure that can ameliorate the pain and splinting associated with multiple rib fractures. Although we experienced no complications, additional investigation is clearly needed.

Adult↗
PubMed2002

Rib fractures after chest physiotherapy for bronchiolitis or pneumonia in infants.

BACKGROUND: The reported causes of rib fractures in infants are: child abuse, accidental injury, cardiopulmonary resuscitation, bone fragility, birth trauma and severe cough. OBJECTIVE: To report chest physiotherapy (CPT) as a new cause of rib fractures in five infants. MATERIALS AND METHODS: We retrospectively identified all infants with rib fractures after CPT for bronchiolitis or pneumonia over a 4-year period in two paediatric and one paediatric radiology units in three university hospitals in Paris. RESULTS: Five boys were identified. Their median age was 3 months. None had any other potential cause of rib fractures. The indication for CPT was bronchiolitis in four cases and pneumonia in one. The median number of rib fractures was four (range 1-5). Fractures were located between the 3rd and 8th ribs; they were lateral in four patients and posterior in one; they were unilateral in four patients and bilateral in one. Evolution was favourable in all cases. The prevalence of rib fractures after CPT during the study period was estimated at 1 in 1,000 infants hospitalised for bronchiolitis or pneumonia. CONCLUSIONS: CPT should be considered a potential, but very rare cause of rib fractures in infants. It can be of clinical relevance when rib fractures are the only feature suggestive of child abuse.

Bronchiolitis↗
PubMed1997

Traumatic first rib fracture: is angiography necessary? A review of 730 cases.

The two most common sites of first rib fracture were at the subclavian sulcus and in the neck of the first rib, posteriorly. Five distinct mechanisms for rib fracture were identified and included: (i) posteriorly directed trauma to the upper thorax or shoulder girdle; (ii) a direct blow to the sternum and anterior chest wall; (iii) a blow fracturing the clavicle; (iv) a strong sudden contraction of the scalenus anticus muscle; and (v) radiographic findings of a first rib fracture without history of trauma. Isolated first rib fracture regardless of mechanism of injury, results in a low incidence of major vascular injury (mean 3%), although with fracture displacement, the incidence is higher. First rib fracture associated with concomitant head, thoracic, abdominal, or long bone trauma was associated with vascular injury in 24% of cases. According to this review, specific indications for subclavian artery and aortic arch arteriography in patients with traumatic first rib fracture include widened mediastinum on chest radiography, upper-extremity pulse deficit, posteriorly displaced first rib fracture, subclavian groove fracture anteriorly, brachial plexus injury and expanding hematoma.

Angiography↗
PubMed1997

Mechanical factors associated with posterior rib fractures: laboratory and case studies.

OBJECTIVE: The objective of this study was to explore the mechanical factors associated with posterior rib fractures. MATERIALS AND METHODS: Radiographs were reviewed in ten cadavers where rib fractures were produced by opening a median sternotomy with a sternal retractor. A second study used CT to evaluate for rib fractures following digital sternal depression and anteroposterior bimanual thoracic compression in three rabbits. Lastly, two cases of accidental posterior rib fractures in children were reviewed. RESULTS: In the cadaver studies, ten rib fractures were noted, all at or medial to the costotransverse process articulations. In the rabbit study, 13 posterior rib fractures were noted, all occurring with excessive posterior levering of the ribs during bimanual compression. The accidental posterior rib fractures occurred with severe anteroposterior thoracic compression as children were decelerated into a car dashboard or struck by a car. CONCLUSION: Posterior rib fractures require excessive levering of the posterior ribs at the costotransverse process articulation. When these fractures occur in accidental situations, they require massive forces that entail similar mechanics to those occurring in abusive settings.

Accidents, Traffic↗
PubMed2005

[CT rendering and mechanical analysis for rib fracture inextricable on X-ray chest film in legal medical practice].

OBJECTIVE: To explore an approach of CT rendering and mechanical analysis for rib fracture that was inextricable on X-ray film in legal medical practice. METHODS: 17 cases with rib fracture undetermined on X-ray chest film in legal medical practice underwent CT scans. The thin slices (0.75 mm or lmm) of images were reconstructed with smooth and sharp kernel. The multiplanar reformatted images along rib and surface shaded display were obtained to investigate rib fracture. RESULTS: All rib fractures were accurately displayed by CT scan and MPR images along rib. The torque that caused rib fracture was divided presumably into vertical and rotary types. The two kinds of rib fracture, composed of vertical and rotary type, were proposed. CONCLUSION: CT scan with thin slice and MPR images can definitely reveal the rib fracture unresolved on X-ray film in legal medical practice. The proposition of two kinds of torque will be help avoid misunderstanding acute rotary type of rib fracture as old healed one.

Adult↗
PubMed2006

Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review.

BACKGROUND: There is a diagnostic dilemma when a child presents with rib fractures after cardiopulmonary resuscitation (CPR) where child abuse is suspected as the cause of collapse. We have performed a systematic review to establish the evidence base for the following questions: (i) Does cardiopulmonary resuscitation cause rib fractures in children? (ii) If so, what are the frequency and characteristics of these fractures that may help to distinguish them from rib fractures caused by physical abuse? METHODS: We performed a literature search of original articles, references, textbooks, and conference abstracts, published in any language from 1950 to 1 October 2005. Articles were identified from ASSIA, Caredata, Medline, Ovid Medline in Process, ChildData, CINAHL, Embase, ISI Proceedings, SIGLE, Science Citation Index, Social Science Citation Index, and TRIP databases. We included all studies that addressed rib fractures and CPR in children less than 18 years, and excluded review articles, expert opinion, consensus guidelines, and studies that were significantly methodologically flawed on critical appraisal. Each study underwent two independent reviews (with a third review if there was disagreement). Each reviewer used standardized criteria for study definition, data extraction, and critical appraisal, to determine the quality of the study and to establish if it met the inclusion criteria of this systematic review. FINDINGS: Of the 427 studies reviewed, 6 were included: 1 case control, 4 cross-sectional, and 1 case series. These represent data on 923 children who underwent CPR. Three children sustained rib fractures as a result of resuscitation; all three of these had fractures that were anterior (two mid-clavicular and one costo-chondral). We did not find any child in the literature who had a posterior rib fracture due to CPR. Resuscitation was performed variably by both medical and non-medical personnel. CONCLUSION: Rib fractures after cardiopulmonary resuscitation are rare. When they do occur, they are anterior and may be multiple. As the studies performed to date did not use the most sensitive techniques for detecting rib fractures, further prospective studies of children would be valuable to provide additional clarification on this question.

Adolescent↗
PubMed1990

Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study.

UNLABELLED: The presence of major chest wall injury is an indication for transfer to a Level I trauma center. We hypothesized that the presence of three or more rib fractures on initial chest X-ray would identify a small subgroup of patients with a high probability of requiring trauma center care. All trauma discharges in Maryland between 1984 and 1986 (N = 105,683) were reviewed. Patients were divided by the presence of rib fractures (no rib fractures, 1-2 fractures, 3+ fractures) and age in years (0-13, 14-64, 65+). RESULTS: The presence of three or more rib fractures in the pediatric age group was rare and precluded further evaluation. When comparing patients with 1-2 rib fractures versus 3 or more rib fractures, significant differences were found in mortality, mean Injury Severity Score, mean hospital stay and mean number of ICU days (p less than 0.001). The significant differences occurred in all age groups 14 years old and older. The presence of three or more rib fractures increased the relative risk of splenic injury (6.2) and liver injury (3.6) but did not predict the presence of aortic injury. CONCLUSION: The presence of 3 or more rib fractures identifies a small subgroup of patients (2.4%) likely to require tertiary care. This triage tool is useful in all patients over the age of 14 years.

Adolescent↗
PubMed2000

Rib fractures in infants: red alert! The clinical features, investigations and child protection outcomes.

OBJECTIVE: To examine clinical features, investigation methods and outcomes of infants with rib fractures. METHODOLOGY: All infants aged 2 years or younger who presented over a 5-year period with documented rib fractures were identified from the medical records database of a tertiary referral paediatric hospital and data collected by retrospective chart review. Additional data regarding notifications and placements were obtained from the Department of Families Youth and Community Care, Queensland. RESULTS: Rib fractures were attributed to child abuse in 15 of 18 infants identified. The initial presentation in the abused infants was most often as a result of intracranial pathology and limb fractures. In four cases the rib fractures were incidental findings when abuse had not been suspected. Bone scintigraphy revealed eight previously undetected rib injuries in four cases. In three cases of abuse, the rib fractures were an isolated finding. Three of the infants with inflicted rib injuries were discharged home. In one such infant a significant re-injury occurred. Three returned home with implicated adults no longer in residence, and nine spent a mean period of 12 months in foster care. CONCLUSIONS: Rib fractures in infancy are usually caused by severe physical abuse. Accidental rib fractures are rare in infants and result from massive trauma. Rib fractures, multiple or single, may occur in isolation in abused infants. The implications of such injuries must be recognized to ensure appropriate, safe and consistent child protection outcomes. Bone scintigraphy is more sensitive than radiographs in the detection of acute rib fractures and should be performed in all cases of suspected infant abuse.

Acute Disease↗
PubMed1999

Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash.

BACKGROUND: Pain from rib fracture pain may affect pulmonary function, morbidity, and length of intensive care unit stay. Previous trials have varied epidural technique within the study and have used several outcome variables. METHODS: The charts of patients who sustained rib fractures after a motor vehicle crash between January 1, 1994, and June 30, 1997, were reviewed. Data were collected from 64 patients who had three or more rib fractures and initiation of intravenous patient-controlled analgesia with morphine or thoracic epidural analgesia with bupivacaine and fentanyl within 24 hours of admission. RESULTS: Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores were not significantly different between groups. Patients in the epidural group had significantly more rib fractures and were significantly older. Patients who received epidural analgesia had significantly lower pain scores at all times. There were no differences in the lengths of intensive care unit or hospital stays, or the incidence of pulmonary complications or organ failure between groups. CONCLUSION: Thoracic epidural analgesia with bupivacaine and fentanyl provided superior analgesia than intravenous patient-controlled analgesia morphine.

APACHE↗
PubMed1990

Rib fractures in children: a marker of severe trauma.

The early recognition of life-threatening injury is paramount to the prompt initiation of appropriate care. This study assesses the importance of multiple rib fractures as a marker of severe injury in children. We analyzed physiologic, etiologic, and injury data for 2,080 children with blunt or penetrating trauma aged 0-14 years consecutively admitted to a Level I pediatric trauma center. Analysis of variance, Student's t-test, and the Chi-square test of independence were used to test for differences between children with rib fractures and other children. Probability of survival was modeled using stepwise logistic regression. There were 14 deaths among 33 children with rib fractures, a mortality rate of 42%. Child abuse accounted for 63% of the injuries to children less than 3 years old, while pedestrian injuries predominated among older children. Children with rib fractures were significantly more severely injured than children with blunt or penetrating trauma but without rib fractures. When compared to children without rib fractures, children with rib fractures had a higher mortality rate, but no statistically significant difference in morbidity. The mortality rate for the 18 children with both rib fractures and head injury was 71%. A logistic model with variables measuring severity of head injury and number of ribs fractured correctly predicted survival in more than 85% of children with thoracic trauma. Although rib fractures are rare injuries in childhood, they are associated with a high risk of death. The risk of mortality increases with the number of ribs fractured. The combination of rib fractures and head injury was usually fatal.

Adolescent↗
PubMed2002

Isolated rib fractures in elderly patients: mortality and morbidity.

OBJECTIVES: To describe the management, morbidity and mortality seen with isolated rib fractures in elderly patients and assess the need for hospitalization. DESIGN: A case series. SETTING: A tertiary care centre in Tel Aviv. METHODS: Hospital records of 77 elderly patients (age 65 yr and older) admitted with isolated rib fractures were reviewed over a 9-year period. MAIN OUTCOME MEASURES: Demographic, medical and hospitalization data, blood hemoglobin and oxygen saturation levels. RESULTS: The number of fractured ribs was found to correlate with the morbidity (p = 0.027) and mortality (p = 0.006). There were no significant differences in these rates with respect to comorbidity except for diabetes (higher morbidity) and congestive heart failure (higher mortality). Twenty-eight patients (36%) had pulmonary complications and 1 had cardiac complications. Pulmonary complications were fatal in 6 patients (7.8%). Multivariate analysis of the factors related to morbidity demonstrated that only oxygen saturation (p = 0.0009) and diabetes (p = 0.03) correlated significantly. CONCLUSIONS: In spite of significant morbidity and mortality in elderly patients with isolated rib fractures, prediction of the prognosis for these patients is presently not possible. Admission for observation and treatment is therefore justified and beneficial.

Aged↗
PubMed2005

Rib fractures in chronic alcoholic men: Relationship with feeding habits, social problems, malnutrition, bone alterations, and liver dysfunction.

Rib fractures are common in alcoholics. This high prevalence might be due to ethanol-associated malnutrition, bone disease, liver dysfunction, or the peculiar lifestyle of the alcoholic with frequent trauma and altercations. In this study we try to discern the role of these factors on rib fracture (assessed on a plain thoracic X-ray film) in 81 consecutive alcoholic patients, 25 of them cirrhotics. Serum albumin, prothrombin aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT), gamma-glutamyl transpeptidase, C-terminal cross-linking telopeptide of type 1 collagen, osteocalcin, insulin growth factor 1, 1,25-dihydroxyvitamin D, parathyroid hormone, estradiol, free testosterone, and corticosterone were measured, and the patients also underwent assessment of bone mineral density by a HOLOGIC QDR-2000 bone densitometer (Waltham, MA, USA). Body mass index, triceps skinfold, and brachial perimeter were also determined, and the patients and their families were asked about tobacco consumption, social and familial links, consumption of ethanol by other members of the family, kind of job, and feeding habits. Forty-two male nondrinker sanitary workers of similar age served as controls. Forty of the 81 patients showed rib fractures. There was a statistically significant association between rib fractures and disruption of social and familial links, irregular feeding habits (in bars or pubs, not at home), ethanol consumption by close relatives, and intensity of tobacco consumption, but not between rib fractures and liver function tests, nutritional parameters, or bone mineral density, besides a nearly significant trend (p = .053) with the presence of osteopenia at the femoral neck. Patients with major withdrawal symptoms at admission also presented more frequent rib fractures. We conclude that rib fractures in alcoholics are related to the peculiar lifestyle of these patients rather than to bone alterations, liver dysfunction, or nutritional status.

Absorptiometry, Photon↗