Question Of The Day #68

This elderly man presents to the Emergency Department after a mechanical fall down the stairs with left flank pain.  He is on anticoagulation.  His chest X-ray shows 3 lower rib fractures.  The diagnosis of rib fractures is clinical in conjunction with imaging.  A history of rib trauma with pleuritic chest pain, tenderness over the ribs, and skin ecchymoses over the chest all support a diagnosis of rib fracture.  Chest X-ray is often performed as an initial test, but it should be noted that about 50% of rib fractures are not able to be visualized on chest radiography alone.  Bedside ultrasonography and CT scanning are more sensitive in detecting rib fractures than plain radiography.  Treatment for rib fractures is mainly supportive and includes pain management and incentive spirometry (or regular deep inspiratory breaths) to prevent the development of atelectasis or pneumonia as complications.  Many patients with rib fractures can be discharged home with these supportive measures.

Another important part of rib fracture management is evaluation for the complications or sequalae of rib fractures.  This includes pulmonary contusion, pneumonia, atelectasis, flail chest, traumatic pneumothorax or tension pneumothorax, hemothorax, and abdominal viscus injuries.  Elderly patients with multiple rib fractures are more likely to have poor outcomes and should be admitted for close observation.  Admission to the hospital for pain management (Choice A) may be needed in this case, but it is not the best next step.  Placement of a chest tube (Choice C) is not needed in this case as there are no signs of a pneumothorax.  Incentive spirometry (Choice D) is important to prevent atelectasis or pneumonia, but it is not the best next step.  The presence of multiple lower rib fractures (ribs #9-12) as seen in this case should prompt evaluation for abdominal injuries, such as hepatic or splenic lacerations.  Potential abdominal injuries should be of greater concern since this patient is on anticoagulation for his atrial fibrillation.  The best next step is a CT scan of the chest, abdomen, and pelvis (Choice B).