Rib Fractures

Question 1

A 79-year-old male patient is admitted to the emergency department after a fall. He has a history of ischaemic heart disease and prostate cancer but is normally well and mobile.

What is your initial management?

Answer 1

Could me minor or very serious - assume major trauma until proven otherwise

• The patient needs to be assessed with a full “hands-of” handover to the trauma team unless there is catastrophic bleeding or a life- threatening event.
• A primary survey should be performed to include treatment of each body system as indicated. It would follow an ABCDE approach.
• A trauma CT scan is the priority in order to determine the location of injuries and further interventions required.
• Transfer of patient to appropriate location: ward, intensive care unit or theatre for further treatment and management.

Question 2

The patient is alert and gives a history of tripping over his cat at home onto the tiled kitchen floor. He is complaining of pain in his right chest. What are your concerns?

Answer 2

• Cause of the fall – likely mechanical, but other factors should be investigated e.g. syncope.
• Duration of his chest pain; if prior to the fall, the pain could indicate a myocardial ischaemic event; if following the fall, it could suggest a pneumothorax and/or rib fractures.
• Other injuries due to the fall.

Question 3

A trauma CT scan shows four right-sided rib fractures and no other internal injuries.

Which ribs are most commonly fractured?

Answer 3

• Ribs 1–3 tend to be protected by the clavicle and shoulder joint, so usually require a high-impact force to be fractured.
• Ribs 4–10 are most commonly fractured.
• Ribs 11 and 12 are less likely to be fractured, as they are relatively
  flexible.

Question 4

What are the priorities in the management of this patient?

Answer 4

The priority here is risk mitigation, which can be achieved in several different ways.

Analgesia:
* Multimodal analgesia should be administered, including simple analgesia, opioids and other adjuncts such as lidocaine patches and gabapentin. Regional anaesthesia may be especially helpful where the above measures are insufficient to allow coughing, deep breathing or physiotherapy.

• Early aggressive regional anaesthesia has been shown to reduce mortality, with the best evidence base for thoracic epidurals and paravertebral blocks. However, other chest wall blocks are becoming popular and are used on many units.
• Local guidelines or rib fracture pathways should ensure a stepwise approach to analgesia.

Question 5

What are the priorities in the management of this patient?

Continued…?

Answer 5

Assessment:
* A multidisciplinary approach is vital for effective management of elderly patients with rib fractures, including review by appropriate medical teams, orthogeriatricians, physiotherapy, senior nursing staff, anaesthetists and the acute pain team.

• History: Should focus on comorbidities, falls, frailty and medications (particularly the use of blood thinners).
• Examination: Look for signs of flail chest, contusions and other lung pathology. A full respiratory examination should be conducted to assess the effect of the injury on the patient’s oxygenation and ventilation.
• Investigations: Depending on the situation, it may be useful to take blood for an arterial blood gas, full blood count, urea and electrolytes and a clotting screen.

Question 6

What are the priorities in the management of this patient?

Continued…?

Answer 6

Location:
* Given the high mortality, this patient should be managed on a high dependency unit.

Ventilation:
* The patient is at high risk of atelectasis, pneumonia and respiratory failure due to hypoventilation and a poor cough secondary to pain.

• Initially, the patient should be prescribed supplementary oxygen with nasal cannulae or a facemask to maintain adequate saturations.
• High flow nasal cannulae or non-invasive ventilatory techniques should be considered if the above is not effective and the patient becomes hypoxic or hypercapnic.
• Early respiratory physiotherapy is key, focusing on techniques such as deep breathing and coughing, and incentive spirometry.

Question 7

What regional techniques can be considered in this patient?

Answer 7

• Serratus anterior block/catheter.
• Paravertebral block/catheter.
• Erector spinae plane block/catheter.
• Thoracic epidural.

Question 8

What are the benefits of a paravertebral catheter compared to a thoracic epidural in this patient?

Answer 8

• Analgesia from a paravertebral catheter is equally effective as a thoracic epidural.
• Avoids the side effects and risks associated with epidurals e.g. dural puncture, sympathetic blockade and urinary retention (particularly in a patient with prostate cancer).
• A paravertebral block is easier to perform with ultrasound guidance.
• The patient can remain mobile, which may decrease the risk of other
  complications e.g. venous thromboembolism.