Rib Fracture

You are the CT1 covering all surgical specialities at a rural district general hospital. You have been called to A&E to see a 24-year old climber who fell 10 meters down the side of a rock face. A&E had performed a CT head which was normal. He was complaining of left sided chest pain, so a chest x-ray was performed but has not yet been reviewed. How would you proceed? 

Example answer introduction
This is a plain P/A radiography of the chest. The most obvious abnormality is a transverse fracture of one of the ribs. My main concern is the possibility of underlying lung injury. I would asses this patient immediately using the ATLS protocol, implement an initial management plan and discuss this patient with the general surgery/orthopaedic registrar. 
Initial Assessment and Simultaneous Resuscitation:
On arrival, manage the patient using an A to E approach according to the Advance Trauma Life Support Algorithm.
  • Airway with C-spine control
    • Check that airway is patient
  • Breathing
    • oxygen saturations, examine chest, examine work of breathing, breathing depth
    • if concerns give high flow oxygen through a non-rebreathe mask
  • Circulation
    • pulse, blood pressure, capillary refill time, skin turgor, fluid input/output
    • ensure IV access- 2 large bore etc- bloods as above, consider catheter
    • Give fluid challenge 500ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol. Avoid deep probing open any neck wounds
    • If hypovolaemic think “blood on the floor + four more” - intrathoracic, intraperitoneal, retroperitoneal, pelvis/thigh – areas of internal haemorrhage
  • Disability - GCS, pupils, blood sugar, temperature
  • Exposure-  systemic signs of shock, other injuries
Provide constant reassessment during this acute phase.
Specific Chest Examination
  • Auscultation
  • Percussion
  • Tracheal deviation
It is important to say you will cover the patient at the end to prevent hypothermia. 

Focused history​​

  • Allergies

  • Medications 

  • Past medical history including previous surgery

  • Last meal

  • Events leading up to this point

Example questions to progress the station

Q1 - On examination the trachea is deviated to the right. There is bruising and tenderness on the lateral aspect of the left chest wall, with reduced air entry, hyperresonant percussion sounds and he is increasingly gasping for breath. What do you think may have happened?

Answer

This is consistent with a left tension pneumothorax. This is an emergent threat to life and I would perform needle thoracocentesis with a large bore cannula in the 2ndintercostal space in the mid-clavicular line with aseptic technique. Once decompression has been assured I would arrange for a chest drain to be inserted (myself if capable or by Registrar/A&E/Respiratory) and repeat the chest x-ray. 

I would re-start my A-E assessment:

  • Airway with C-spine control

    • Check that airway is patient

  • Breathing

    • oxygen saturations, examine chest, examine work of breathing, breathing depth

    • if concerns give high flow oxygen through a non-rebreathe mask

  • Circulation

    • pulse, blood pressure, capillary refill time, skin turgor, fluid input/output

    • ensure IV access- 2 large bore etc- bloods as above, consider catheter

    • Give fluid challenge 500ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol. Avoid deep probing open any neck wounds

    • If hypovolaemic think “blood on the floor + four more” - intrathoracic, intraperitoneal, retroperitoneal, pelvis/thigh – areas of internal haemorrhage

  • Disability - GCS, pupils, blood sugar, temperature

  • Exposure-  systemic signs of shock, other injuries

Once again - reassess after any intervention. 

Q2 - What is your initial management in suspected, uncomplicated rib fracture?

Immediate management and further investigations

​​Management

  • Adequate fluid resuscitation

  • Analgesia according to WHO ladder, up to morphine PCA.

  • Escalate to Registrar if unstable. 

  • Oxygen if required

  • Monitor in high level care particularly if elderly, frail, underlying lung disease. 

  • Frequent reassessment - things can deteriorate quickly

  • Keep patient and any relatives informed

  • Document, document, document!!!

Investigations

If looking for complications of rib fractures for example in a deterioration CT thorax may be useful. FAST scanning in ED may also be of use here. 

Remember to document your findings and management plan and inform the patient/parents.​

Escalation
Simple rib fractures without underlying lung injury can be managed on an outpatient basis is the patient is able to cough and clear their alveolar secretions. Patients unable, or with a weak cough, should be admitted for adequate analgesia until such time they are able to. Elderly patients and those with 3 or more rib fractures should be managed in the ICU setting.  
Consider discussion with:
- ED major trauma team
- ICU / HDU - if patient requires admission for monitoring
- Know where these patients are usually monitored. It can be cardiothoracics, general surgery, orthopaedics or trauma. 
Useful Resources
Multiple rib fracture management
Review of traumatic rib fractures

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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