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Clinical rib fractures: are follow-up chest X-rays a waste of resources?
Rib fractures (RFs) are estimated to be present in 10 per cent of all traumatic injuries. However, up to 50 per cent of all fractures go undetected on the screening chest X-ray (CXR). The purpose of this study was to identify the incidence of clinical (CRFs) and objective rib fractures (ORFs) as well as to examine the utility of the routine follow-up CXR with regard to patient recovery and healthcare cost. We identified patients sustaining RF in addition to other traumatic injuries with an Injury Severity Score (ISS) < or = 15 and RF as the primary pathology. Five hundred fifty-two patients sustained blunt thoracic trauma with resultant RF. Two hundred nine patients had RFs and an ISS < or = 15. The average ISS was 8. Follow-up films illustrated that 93 per cent of CRFs had resolution of any pathology, 4 per cent had persistent X-ray findings, and 4 per cent were lost to follow-up. Ultimately 93 per cent of patients with CRF were able to resume daily activities without disability and 3 per cent incurred lifestyle changes at home or work, which was significantly better than those with ORFs (P < 0.05). Follow-up films produced no change in clinical management and cost approximately $2000/year. The prognosis for CRFs is excellent if treatment consists of appropriate pain management and pulmonary rehabilitation. We do not advocate routine follow-up CXRs in addition to physical examination for the evaluation of CRFs unless clinical deterioration is evident.
Presence of three or more rib fractures as an indicator of need for interhospital transfer.
During a 42-month period, 3,282 patients with blunt trauma were admitted to our hospital. Group I (n = 3,143) was defined as patients sustaining zero to two rib fractures, Group II (n = 139) as patients sustaining three or more rib fractures. Groups I and II differed in age and mechanism of injury. Two other descriptive variables (sex and year of admission) showed statistically significant associations with outcome. To adjust for the joint effect of these four variables, a log-linear model (binary outcomes) or a linear regression model (continuous outcomes) was used. We defined need for interhospital transfer (NIT) based on the following: death, an Injury Severity Score of greater than or equal to 16, or direct admission to the operating room or intensive care unit. We conclude that the presence of three or more rib fractures identified a group of patients requiring transfer to a trauma center (positive predictive value = 92.8%). A population-based study is needed to verify this finding.
Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures.
To evaluate the efficacy of opiate administration regimens, 32 patients with multiple rib fractures were prospectively randomized to receive either continuous epidural (ED) or continuous intravenous (IV) infusions of fentanyl. Dosage was titrated to individual subjective pain relief. Ventilatory function tests (VFTs), arterial blood gases (ABGs), and visual analog scores were obtained before and after the institution of analgesia. Post-analgesia values were compared with pre-analgesia values using a two-tailed paired t-test looking for significant changes produced by the analgesic method. Both methods significantly improved analog pain scores. The ED method produced improvement in both maximum inspiratory pressure (MIP) and vital capacity (VC), whereas IV analgesia only produced improvement in VC. Intravenous fentanyl produced increases in PaCO2 and decreases in PaO2, whereas no significant changes in ABGs were observed with ED fentanyl administration. Side effects were similar between the groups, with pruritus being more pronounced with ED fentanyl administration. The data demonstrate that the continuous ED fentanyl method offers excellent relief of pain and improvement in ventilatory function and has distinct advantages over IV fentanyl administration with respect to changes in ABGs and MIP. The continuous infusion of epidural opiates should be the preferred analgesic method for patients at high risk of developing pulmonary complications following multiple rib fractures.
[Rib fractures after chest physiotherapy: a report of 2 cases].
The 2000 French consensus conference for acute viral bronchiolitis management underlined the fundamental role of chest physiotherapy. According to Chalumeau and al., rib fractures were found out in 1/1000 children hospitalized for bronchiolitis or pneumonia. However, such complication of chest physiotherapy is exceptional. We report 2 cases with third to sixth lateral rib fractures after chest physiotherapy in infants with bronchiolitis. Despite the rarity of these complications, clinicians must keep in mind this etiology while facing rib fractures in infants.
Decreased 99mTc sulfur colloid activity in healed rib fractures.
This report describes 2 patients in whom focal areas of decreased 99mTc sulfur colloid marrow activity were associated with callus formation and healing rib fractures in one case and rib fractures with bony bridging in the second. Since bone marrow scans are occasionally used to select appropriate sites for marrow biopsy in patients with suspected metastatic disease, radiographic correlation of "cold" lesions on marrow scans is recommended prior to biopsy to exclude fracture with callus formation as a benign cause of the abnormality.
An unusual cause of rib fracture following a road traffic accident.
A case is presented which is thought to be the first described example of rib fracture occurring as a result of airbag inflation. It would appear that the propellant cartridge came loose during deployment to form a missile, striking the patient on his chest and fracturing a rib.
Incidence of pneumothorax from intercostal nerve block for analgesia in rib fractures.
BACKGROUND: The incidence of pneumothorax (PTX) after individual intercostal nerve block (INB) for postoperative pain reportedly varies from 0.073% to 19%.1-3 This study investigated the incidence of PTX after INB for rib fractures. METHODS: We conducted a retrospective chart review of patients admitted between January 1996 and December 1999 with rib fractures who received INB. RESULTS: One hundred sixty-one patients received 249 intercostal nerve block procedures (INBPs). An INBP is one session where a set of intercostal nerves are blocked. A total of 1,020 individual intercostal nerves were blocked. There were 14 pneumothoraces. The overall incidence of PTX per patient was 8.7%, with an incidence of PTX per INBP of 5.6%. The incidence of PTX was 1.4% for each individual intercostal nerve blocked. CONCLUSION: The incidence of PTX per individual intercostal nerve blocked is low. INB is an effective form of analgesia, and for most patients with rib fractures one INBP is sufficient to allow adequate respiratory exercises and discharge from the hospital.
Continuous infusion interpleural analgesia for multiple fractured ribs.
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Fractured ribs: unusual presentation of rickets in premature infants.
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Continuous pain relief for multiple fractured ribs.
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Intrathecal morphine and multiple fractured ribs.
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Cord transection by guillotine effect of fractured ribs.
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Epidural analgesic for bronchitic patients with fractured ribs.
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Cough induced rib fracture, rupture of the diaphragm and abdominal herniation.
Cough can be associated with many complications. In this article, we present a 59 year old male patient with a very rare combination of a cough related stress fracture of the ninth rib, a traumatic rupture of the diaphragm, and an abdominal wall herniation. The hernia was repaired through surgical treatment without bowel resection, the diaphragm and the internal and oblique abdominal muscle were adapted, and the abdomen was reinforced with a prolene net. Although each individual injury is well documented in the literature, the combination of rib fracture, abdominal herniation and diaphragm rupture has not been reported.
Rickets with multiple fractured ribs in a premature infant.
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Cardiac perforation secondary to a fractured rib sustained in a ram attack in New Zealand: a review of ovine fatalities and an important lesson regarding the severely injured chest.
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