5.02 Rib Fracture and Costochondral Separation

agk’s Library of Common Simple Emergencies

Presentation

A patient with an isolated rib fracture or a minor costochondral separation usually has a history of falling on the side of the chest, being struck by a blunt object, coughing violently or leaning over a rigid edge. The initial chest pain may subside, but over the next few hours or days pain increases with movement, interfering with sleep and activity and becoming severe with coughing or deep inspiration. The patient is often worried about having a broken rib, and may have a sensation of bony crepitus or abnormal rib movement. Breath sounds bilaterally should be normal unless there is substantial splinting or a pneumothorax or hemothorax is present. There is point tenderness over the site of the injury and occasionally bony crepitance can be felt.

What to do:

• Examine the patient for possible associated injuries; e.g., do an abdominal exam to look for any signs of a splenic or hepatic injury. If there was a significan mechanism of injury, the patietn may require a comprenhensive evaluation to rule out life and limb threatening injuries.
• When there is a history of minor trauma, check for pain with indirect stress on the suspected fracture site. Compress the rib medially if a posterior or anterior fracture is suspected. Compress the rib anteriorly/posteriorly if a fracture is suspected at a lateral location. When pain occurs at the suspected fracture site with indirect stress, this is clinical evidence of a fracture or separation and should be so documented on the chart.
• Obtain any history of chronic pulmonary problems or heavy smoking.
• Unless the patient is elderly or has pulmonary disease, have him try out a rib belt during his wait for x rays.
• Send the patient for a PA & lateral chest x ray to rule out a pneumothorax, hemothorax, evidence of pulmonary contusion, etc. Additional oblique rib films for radiological documentation of a fracture are optional and often unproductive, but these films are indicated when there is a suspicion of multiple rib fractures, especially in the elderly.
• If there is no suspicion of underlying injury and when there is clinical or radiologic evidence of a rib fracture or chondral separation:
  • Provide a potent oral analgesic (Motrin, Aleve, Tylenol with codeine, Lorcet, Percocet).
  • Instruct the patient on the intermittent use of an elastic and velcro rib belt if it reduces pain. Place the top of the belt at the inferior tip of the xyphoid process, tightening it around the chest enough to obtain maximum pain relief. the fib belt may be left on almost continuously for the first one to four days but it should be removed as comfort allows thereafter.
  • Instruct the patient on the importance of deep breathing and coughing (without the rib belt but using a pillow splint) to help prevent pneumonia. Tell him to take enough pain medicine to allow coughing and deep breathing.
  • Provide the patient with an appropriate work excuse and refer him for followup care in 48 hours. Tell him to expect gradually decreasing discomfort for about two weeks, and forbid strenuous activity for approximately eight weeks.
  • Severe worsening of chest pain, shortness of breath, fever or purulent sputum may signal pulmonary complications and should prompt a return visit. A greater incidence of complications can be expected in patients with displaced rib fractures.
• When patients are elderly or have pulmonary or cardiac compromise, or multiple fractures or other injuries which might compromise respiratory dynamics, consider hospitalization for observation, pain control and pulmonary toilet. Blood gases and pulmonary function tests can aid in evaluation of breathing.
• When there is no clinical or radiologic evidence of a fracture, treat the pain as you would any other contusion, using an appropriate analgesic.

What not to do:

• Do not confuse simple rib fractures with massive blunt trauma to the chest. The evaluation and management is quite different.
• Do not tape ribs or use continuous strapping. This will lead to an atelectatic lung prone to pneumonia.
• Do not assume there is no fracture just because the x rays are negative. Rib fractures are often not apparent on x ray, especially when they occur in the cartilagenous portion of the rib. The patient deserves the disability period and analgesics commensurate with the real injury.

Discussion

Most fractures and separations are treated with immobilization, but ribs are a special problem because patients have to continue breathing. In the presence of severe pain one should consider the use of an intercostal nerve block or injection of the fracture hematoma with 0.5% bupivacaine hydrochloride (Marcaine). Because of the risks of pneumothorax or hemothorax, this procedure, in most cases, should be reserved for secondary management when initial treatment has proven ineffective.

References:

• Quick G: A randomized clinical trial of rib belts for simple fractures. Am J Emerg Med 1990;8:277-281.
• Lazcano A, Dougherty J, Kruger M: Use of rib belts in acute rib fractures Am J Emerg Med 1989;7:97-100.

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