Sternal fractures are usually associated with direct blunt ...



Sternal and Rib Fractures

Sternal fractures are usually associated with direct blunt traumatic injury to the chest sustained in a motor vehicle crash, but stress fractures may also be encountered. Sternal fractures are painful injuries resulting in decreased respiratory excursion and pulmonary atelectasis, so outpatient management should consist of adequate analgesia and incentive spirometry. Sternal fractures may be associated with acute life-threatening intrathoracic injuries such as cardiac contusion, mediastinal injury and bleeding, aortic injury, flail chest, pneumothorax or hemothorax, pulmonary contusions and lacerations, and compression fractures of the ribs and thoracic spine. Because of the high morbidity and mortality of concomitant injuries, a high index of suspicion should be held for associated injuries when sternal fracture is diagnosed.



• Patients with isolated rib fractures who are unable to cough and clear secretions adequately should be considered for admission for 24-hour observation.

• Consider admission for patients with underlying lung disease or decreased pulmonary reserve.

• A lower threshold for admission of older persons with isolated rib fractures is warranted because of their higher incidence of hypoventilation, hypercapnia, atelectasis, and pneumonia.[6]

• Specifically in the age group 65 years and older, consider admission for patients age ≥85 years, or with initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 or more unilateral rib fractures, or pulmonary contusion.[6]

• Admission may also allow for observation for occult intra-abdominal organ injury.

• Patients being admitted should have good pain control and be given an incentive spirometer to prevent pulmonary splinting and its resultant complications.[31]

Complications of rib fracture may include the following:

• Respiratory failure: The alteration in chest wall mechanics due to multiple rib fractures increases the work of breathing and the patients with multiple rib fractures are at risk for pulmonary fatigue. Respiratory failure can be due to the chest wall injury (eg, flail chest) but is more commonly due to an underlying pulmonary contusion or development of nosocomial pneumonia, especially if superimposed on a preexisting pulmonary condition.[38]

• Hypoventilation

• Hypercapnia

• Hypoxia

• Atelectasis

• Pneumonia: Pneumonia is one of the most common complications associated with rib fractures. Pneumonia rates vary depending on the number of fractures and age of the patient. The incidence of pneumonia for all patients hospitalized with one or more rib fractures is about 6%.[38]

• Damage to underlying visceral organs

• Pneumothorax (immediate or delayed)[35]

• Hemothorax (immediate or delayed)[35]

• Retained hemothorax: Retained hemothorax refers to the presence of blood/clot in the thoracic cavity that persists in spite of thoracostomy drainage. The risk of empyema is increased in patients with retained hemothorax.[39]

• Aortic injury (immediate or delayed)[40]

• Pulmonary contusion

• Intra-abdominal organ injury[18]

Fractures of the first rib have often been associated with serious head injury, cervical spine injury, delayed subclavian vessel thrombosis, aortic aneurysm, tracheobronchial fistula, thoracic outlet syndrome, and Horner syndrome.[3]

(Horner syndrome is a combination of signs and symptoms caused by the disruption of a nerve pathway from the brain to the face and eye on one side of the body. Horner syndrome is the result of another medical problem, such as a stroke, tumor or spinal cord injury. )

A small percentage of rib fractures do not heal even though a fibrous capsule may envelope the fracture. A nonunion may present months to years after injury and can cause discomfort with respiration due to movement of the fracture site. Some patients find the respiratory restriction due to pain quite disabling.Contributor Information and Disclosures

Author

Sarah L Melendez, MD  Clinical Assistant Instructor, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center and Kings County Hospital Center

Sarah L Melendez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, FACEP  Associate Professor of Emergency Medicine, Residency Program Director, Vice-Chair for Education, Department of Emergency Medicine, University of Kentucky-Chandler Medical Center

Christopher I Doty, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Michelle Ervin, MD  Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

Laurie K Mahoney, MD, FAAEM Attending Physician, Department of Emergency Medicine, Long Island College Hospital, Brooklyn

Laurie K Mahoney, MD, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, and American College of Emergency Physicians

Disclosure: Nothing to disclose.

References

1. Ochi K, Furuya T, Ikari K, Taniguchi A, Yamanaka H, Momohara S. Sites, frequencies, and causes of self-reported fractures in 9,720 rheumatoid arthritis patients: a large prospective observational cohort study in Japan. Arch Osteoporos. 2013;8(1-2):130. [Medline].

2. Colosimo AJ, Byrne E, Heidt RS Jr, Carlonas RL, Wyatt H. Acute traumatic first-rib fracture in the contact athlete: a case report. Am J Sports Med. Jul-Aug 2004;32(5):1310-2. [Medline].

3. Lee SJ, Chu SJ, Tsai SH. Isolated Bilateral First-rib Fractures. J Emerg Med. Jul 21 2008;[Medline].

4. Recinos G, Inaba K, Dubose J, et al. Epidemiology of sternal fractures. Am Surg. May 2009;75(5):401-4. [Medline].

5. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. Dec 1994;37(6):975-9. [Medline].

6. Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL, Ahmed SS. Factors associated with complications in older adults with isolated blunt chest trauma. West J Emerg Med. May 2009;10(2):79-84. [Medline].

7. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. Jun 2000;48(6):1040-6; discussion 1046-7. [Medline].

8. Shorr RM, Rodriguez A, Indeck MC, Crittenden MD, Hartunian S, Cowley RA. Blunt chest trauma in the elderly. J Trauma. Feb 1989;29(2):234-7. [Medline].

9. Wang HW, Xiang Q, Li CQ, Zhou Y. Traumatic vertebral fractures with concomitant fractures of the first rib. Orthop Surg. May 2013;5(2):100-4. [Medline].

10. Richardson JD, McElvein RB, Trinkle JK. First rib fracture: a hallmark of severe trauma. Ann Surg. Mar 1975;181(3):251-4. [Medline].

11. Logan PM. Is there an association between fractures of the cervical spine and first- and second-rib fractures?. Can Assoc Radiol J. Feb 1999;50(1):41-3. [Medline].

12. Hassan AN, Ballester J, Slater N. Bilateral first rib fractures associated with Horner's syndrome. Injury. May 2000;31(4):273-4. [Medline].

13. Al-Hassani A, Afifi I, Abdelrahman H, El-Menyar A, Almadani A, Recicar J, et al. Concurrent rib and pelvic fractures as an indicator of solid abdominal organ injury. Int J Surg. 2013;11(6):483-6. [Medline].

14. Peters ML, Starling SP, Barnes-Eley ML, Heisler KW. The presence of bruising associated with fractures. Arch Pediatr Adolesc Med. Sep 2008;162(9):877-81. [Medline].

15. Boele van Hensbroek P, Mulder S, Luitse JS, van Ooijen MR, Goslings JC. Staircase falls: high-risk groups and injury characteristics in 464 patients. Injury. Aug 2009;40(8):884-9. [Medline].

16. Maxwell CA, Mion LC, Dietrich MS. Hospitalized injured older adults: clinical utility of a rib fracture scoring system. J Trauma Nurs. Jul 2012;19(3):168-74. [Medline].

17. Coris EE, Higgins HW 2nd. First rib stress fractures in throwing athletes. Am J Sports Med. Sep 2005;33(9):1400-4. [Medline].

18. Holmes JF, Wisner DH, McGahan JP, Mower WR, Kuppermann N. Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma. Ann Emerg Med. Oct 2009;54(4):575-84. [Medline].

19. Park S. Clinical Analysis for the Correlation of Intra-abdominal Organ Injury in the Patients with Rib Fracture. Korean J Thorac Cardiovasc Surg. Aug 2012;45(4):246-50. [Medline]. [Full Text].

20. Leport T, Baudrit P, Potier P, Trosseille X, Lecuyer E, Vallancien G. Study of rib fracture mechanisms based on the rib strain profiles in side and forward oblique impact. Stapp Car Crash J. Nov 2011;55:199-250. [Medline].

21. Murphy J, Nyland J, Lantry J, Roberts C. Motorcyclist "biker couples": a descriptive analysis of orthopaedic and non-orthopaedic injuries. Injury. Nov 2009;40(11):1195-9. [Medline].

22. Connolly LP, Connolly SA. Rib stress fractures. Clin Nucl Med. 2004.

23. Chan SS. Emergency bedside ultrasound for the diagnosis of rib fractures. Am J Emerg Med. Jun 2009;27(5):617-20. [Medline].

24. Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute rib fracture. AJR Am J Roentgenol. Dec 1999;173(6):1603-9. [Medline].

25. Kara M, Dikmen E, Erdal HH, Simsir I, Kara SA. Disclosure of unnoticed rib fractures with the use of ultrasonography in minor blunt chest trauma. Eur J Cardiothorac Surg. Oct 2003;24(4):608-13. [Medline].

26. Rainer TH, Griffith JF, Lam E, Lam PK, Metreweli C. Comparison of thoracic ultrasound, clinical acumen, and radiography in patients with minor chest injury. J Trauma. Jun 2004;56(6):1211-3. [Medline].

27. Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures?. Injury. Jun 2004;35(6):562-6. [Medline].

28. Magu S, Yadav A, Agarwal S. Computed tomography in blunt chest trauma. Indian J Chest Dis Allied Sci. Apr-Jun 2009;51(2):75-81. [Medline].

29. Ingalls NK, Horton ZA, Bettendorf M, Frye I, Rodriguez C. Randomized, double-blind, placebo-controlled trial using lidocaine patch 5% in traumatic rib fractures. J Am Coll Surg. Feb 2010;210(2):205-9. [Medline].

30. Easter A. Management of patients with multiple rib fractures. Am J Crit Care. 2001.

31. Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma. Mar 2003;54(3):615-25. [Medline].

32. Mohta M, Verma P, Saxena AK, Sethi AK, Tyagi A, Girotra G. Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs--a pilot study. Journal of Trauma. 2009.

33. [Best Evidence] Carrier FM, Turgeon AF, Nicole PC, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. Mar 2009;56(3):230-42. [Medline].

34. Short K, Scheeres D, Mlakar J, Dean R. Evaluation of intrapleural analgesia in the management of blunt traumatic chest wall pain: a clinical trial. Am Surgery. 1996.

35. Shields JF, Emond M, Guimont C, Pigeon D. Acute minor thoracic injuries: evaluation of practice and follow-up in the emergency department. Can Fam Physician. Mar 2010;56(3):e117-24. [Medline]. [Full Text].

36. Misthos P, Kakaris S, Sepsas E, Athanassiadi K, Skottis I. A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma. Eur J Cardiothorac Surg. May 2004;25(5):859-64. [Medline].

37. Bansidhar BJ, Lagares-Garcia JA, Miller SL. Clinical rib fractures: are follow-up chest X-rays a waste of resources?. Am Surg. 2002.

38. Brasel KJ, Guse CE, Layde P, Weigelt JA. Rib fractures: relationship with pneumonia and mortality. Crit Care Med 2006 [serial online]. 2006;34(6):1642:Accessed April 9, 2012. Available at .

39. [Best Evidence] Karmy-Jones R, Holevar M, Sullivan RJ, et al. Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury. Can Respir J. 2008.

40. Bruno VD, Batchelor TJ. Late aortic injury: a rare complication of a posterior rib fracture. Ann Thorac Surg. Jan 2009;87(1):301-3. [Medline].

41. Kristine A Karlson, MD, Section EditorsPatrice Eiff, MD & John A Marx, MDDeputy Editor Jonathan Grayzel, MD, et al. Rib fractures. UpToDate. Available at . Accessed April 3, 2012.

42. Albers JE, Rath RK, Glaser RS, Poddar PK. Severity of intrathoracic injuries associated with first rib fractures. Ann Thorac Surg. Jun 1982;33(6):614-8. [Medline].

43. Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD. Epidemiology of trauma deaths. Am J Surg. Jul 1980;140(1):144-50. [Medline].

44. Carrier FM, Turgeon AF, Nicole PC, Trépanier CA, Fergusson DA, Thauvette D, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. 2009.

45. Colosimo AJ, Byrne E, Heidt RS Jr, Carlonas RL, Wyatt H. Acute traumatic first-rib fracture in the contact athlete: a case report. Am J Sports Med. Jul-Aug 2004;32(5):1310-2. [Medline].

46. Flagel BT, Luchette FA, Reed RL, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. Oct 2005;138(4):717-23; discussion 723-5. [Medline].

47. Fulda GJ, Giberson F, Fagraeus L. A prospective randomized trial of nebulized morphine compared with patient-controlled analgesia morphine in the management of acute thoracic pain. J Trauma. Aug 2005;59(2):383-8; discussion 389-90. [Medline].

48. Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. J Trauma. Jun 1990;30(6):695-700. [Medline].

49. Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures?. Injury. Jun 2004;35(6):562-6. [Medline].

50. Lee RB, Bass SM, Morris JA Jr, MacKenzie EJ. Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study. J Trauma. Jun 1990;30(6):689-94. [Medline].

51. LoCicero J 3rd, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am. Feb 1989;69(1):15-9. [Medline].

52. Love JC, Symes SA. Understanding rib fracture patterns: incomplete and buckle fractures. J Forensic Sci. Nov 2004;49(6):1153-8. [Medline].

53. Newman RJ, Jones IS. A prospective study of 413 consecutive car occupants with chest injuries. J Trauma. Feb 1984;24(2):129-35. [Medline].

54. Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg. Oct 1982;196(4):481-7. [Medline]. [Full Text].

55. Ruddy RM. Trauma and the paediatric lung. Paediatr Respir Rev. Mar 2005;6(1):61-7. [Medline].

56. Stawicki SP, Grossman MD, Hoey BA, Miller DL, Reed JF 3rd. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc. May 2004;52(5):805-8. [Medline].

57. Trinkle JK, Richardson JD, Franz JL, Grover FL, Arom KV, Holmstrom FM. Management of flail chest without mechanical ventilation. Ann Thorac Surg. Apr 1975;19(4):355-63. [Medline].

58. Wilson JM, Thomas AN, Goodman PC, Lewis FR. Severe chest trauma. Morbidity implication. Arch Surg. Jul 1978;113(7):846-9. [Medline].

59. Woodring JH, Fried AM, Hatfield DR, Stevens RK, Todd EP. Fractures of first and second ribs: predictive value for arterial and bronchial injury. AJR Am J Roentgenol. Feb 1982;138(2):211-5. [Medline].

 

[pic]

[pic]

 

Aortic injury is closely associated with a widening of greater than 8 cm measured at the widest points of the mediastinum on an upright anteroposterior chest radiograph.

Normal sonogram of the anterior chest wall using a 7.5-MHz linear transducer. The double arrows show the short-axis view of a rib, with its hyperechoic margin and posterior acoustic shadowing. P denotes the "pleural line" that is also hyperechoic and that should not be mistaken as the rib margin.

Long-axis view of a fractured left third rib of a patient using a 12-MHz linear transducer. The disruption of the hyperechoic cortical alignment is shown by the arrows.

[pic]

[pic]

 

View Table List

 



Sternal and Rib Fractures QUIZ

1. With which type of trauma are sternal fractures associated?

a. Pentrating

b. Blunt

c. Thermal

d. Blast

2. Patients being admitted for sternal and/or rib fractures should be given

a. An incentive spirometer and pain analgesia

b. A rib corset

c. An ace wrap around the chest

d. All of the above

3. Pneumonia is one of the most common complications associated with rib fractures.

a. True

b. False

4. Other diagnoses to look for in patients w/ sternal and/or rib fractures are

a. Pneumothorax

b. Hemothorax

c. Pulmonary contusion

d. All of the above

5. Sternal fractures are painful injuries resulting in decreased respiratory excursion and pulmonary atelectasis, management should consist of adequate pain medication and incentive spirometry.

a. True

b. False

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download