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What is the diagnosis?

Fracture of the left ribs 6-8

Image 2: Plain radiograph of the left ribs with annotation pointing to the rib fractures. Radiopaedia: Case courtesy of Dalia Ibrahim, Radiopaedia.org, rID: 30339)

• Pearl: Ribs 4 through 10 are typically the most vulnerable while ribs 11 through 12 are more mobile and therefore more difficult to break [8]. The most feared complication of rib fractures is the flail chest where three or more rib fractures at two points on the involved ribs, creating a floating rib segment and causing this segment to move paradoxically with the rest of the chest wall. The mortality rate of flail chest is between 10% to 15% [9]. 

What is the mechanism of injury?

Although rib fractures most often result from trauma, they can also be pathologic, arising from conditions such as metastatic cancer. 

• Pearl: Since children tend to have more elastic ribs than adults do, children are less likely to sustain rib fractures. Therefore, children with rib fractures is a sign of significant trauma and should warrant an investigation of possible child abuse [4, 7]. In the elderly, falls are a common etiology of rib fractures and are associated with higher mortality and morbidity than younger patients [3]. 

What physical exam findings are expected?

On examination, rib fractures can present with tenderness to palpation, ecchymosis, crepitus, or palpable deformities. 

Which imaging modalities can be used?

Plan chest radiographs or dedicated rib radiographs will typically be used to identify rib fractures. However, chest radiographs are limited and can only diagnose about 50% of isolated rib fractures [1]. Chest computed tomography (CT) scan is the gold standard of detecting rib fractures, although the fractures detected may not be clinically significant. 

• Pearl: Point-of-care ultrasonography can reliably detect rib fractures along with complications of rib fractures such as pneumothorax [10]. 

Image 3. CT imaging with a left posterior rib displaced fracture. Radiopaedia: Case courtesy of The Radswiki, Radiopaedia.org, rID: 11886)

What is the management in the ED?

For simple, isolated rib fractures, conservative therapy is usually adequate which includes appropriate analgesia, rest, and ice. Incentive spirometer use is encouraged to help prevent pneumonia or lung atelectasis. Intercostal nerve blocks can also be applied to aid in pain control [5].

Intercostal nerve block:

• Typically a long-acting anesthetic such as bupivacaine or ropivacaine are used in these procedures. These injections can be done under ultrasound guidance or by using anatomic landmarks. 

  • Anatomic Landmark: After cleansing and anesthetizing the skin, the physician should create traction on the patient’s skin with their palpating hand. Typically a 22g 50mm long needle is used for these blocks. The needle should enter the skin at a 20-degree angle cephalad at the inferior aspect of the middle portion of the rib. Once contact is made with the rib, the provider can remove their palpating hand, and the needle should be advanced another 1-3mm until a subtle “pop” is felt as the needle advances through the fascia and muscle. After negative aspiration, inject 3-5mL of local anesthesia [2].

  • Ultrasound-Guided: Ultrasound guidance may decrease the chance of intravascular injection, pneumothorax, and allows injection closer to the midline than anatomic landmarks. The individual ribs to be blocked should be marked out as with the landmark technique. The ultrasound probe is then placed in a sagittal plane about 4 cm lateral to the spinous process. The ribs are visualized as a shadow while the pleura and lung are visualized anterior to the intercostal space. The needle can then be inserted in or out of a plane to the transducer and advanced until the tip is just below the inferior border of the rib. After negative aspiration, 3 to 5 mL of local anesthetic is injected, and the pleura should be visualized being pushed away [2].

  • Ultrasound-guided intercostal nerve block

When do you consult a surgical service?

A surgical service (trauma surgery, cardiothoracic surgery, orthopedics surgery) should be consulted if rib fixation is indicated. Rib fixation may be indicated for flail chest, multiple displaced rib fractures, or rib fractures that cause respiratory failure, or refractory pain. The surgical team will vary amongst hospital systems.