RibScore

Introduction
Rib fractures are common injuries among patients sustaining blunt trauma (about 9-10%) and are markers of severe bodily and solid organ injury (Witt & Bulger, 2017). They are also associated with significant morbidity and mortality (10% mortality in adults), especially in the frail and elderly (20% mortality in elderly), mostly attributed to pulmonary complications (Brasel et al., 2017). Further, the number of rib fractures correlates with mortality and complication risk, such as increased risk of death, pneumonia, ARDS, pneumothorax, and aspiration pneumonia. Underlying problems associate with morbidity and mortality include: hypoventilation due to pain, impaired gas exchange in damaged lung underlying the fractures, and altered breathing mechanics (Easter, 2001). Clinical and radiographic scoring systems have been developed for patients with thoracic trauma and rib fractures for risk assessment. Chapman and colleagues (2016) established RibScore, a radiographic scoring system assessing presence of ≥6 rib fractures, bilateral fractures, flail chest, ≥3 severely displaced fractures, first rib fracture, and presence of fractures in the anterior, lateral and posterior regions. This scoring system was associated with development of pneumonia, acute respiratory failure, and tracheostomy. 

Management of patients with rib fractures, to include therapeutic interventions, are likely to vary by institution. Some interventions, such as pulmonary hygiene, lack data in improving patient outcomes (Brasal et al., 2017). The Western Trauma Association (Brasel et al., 2017) has published guidelines in the management of rib fractures. Witt & Bulger (2017) describe an evidence-based comprehensive rib fracture management protocol. emDocs (Cohen, Kern, Koyfman & Long, 2022) highlight a case study detailing work up and management of an 82-year old with rib fractures.

Chapman and colleagues (2016) established RibScore, a radiographic scoring system assessing presence of ≥6 rib fractures, bilateral fractures, flail chest, ≥3 severely displaced fractures, first rib fracture, and presence of fractures in the anterior, lateral and posterior regions. This scoring system was associated with development of pneumonia, acute respiratory failure, and tracheostomy. 

Scoring

The Ribscore is calculated by the sum of the selected points for each variable. 

Recommendation

 RibScore ( ≥ 4): Greater risk of pneumonia, respiratory failure and tracheostomy. Consider admitting the patient to a monitored bed (e.g. - ICU, stepdown) and treat any pain or respiratory complaints.

Considerations

Elderly patients (> 65 years) have at least a 20% mortality that is often related to progressive respiratory failure and pneumonia (Stawicki et al., 2004). However, the Western Trauma Association (WTA) states that age is often arbitrary and measures of fragility are a better indicator when identifying patients who are physiologically old (Brasel et al., 2016). As a general rule, the WTA recommends ICU admission in elderly patients with > 2 acute rib fractures. However, patients with underlying pulmonary dysfunction, or those who are frail, consideration should be given to using a lower age threshold regardless of signs of respiratory compromise at the time of admission. Similarly, for those older than 65 who have no underlying comorbidities, minimal pain, and are in good overall health, a nonmonitored setting may be appropriate.

Management

• Consider admitting the patient to a monitored bed (e.g. - ICU, stepdown) and treat any pain or respiratory complaints.

• The Rib Injury Guidelines (RIG) Score can be used to guide triage of traumatic rib fracture patients (Nelson et al., 2022).

• Consider repeat imaging in patients with any of the following risk factors due to higher risk for a delayed hemothorax:

  • Respiratory deterioration

  • ≥6 rib fractures

  • Post-operative patients

  • Anticoagulation

  • Patients who had a thoracostomy tube placed and then removed

• Pain control and pulmonary hygiene strategies 

Chapman BC, Herbert B, Rodil M, Salotto J, Stovall RT, Biffl W, Johnson J, Burlew CC, Barnett C, Fox C, Moore EE, Jurkovich GJ, Pieracci FM. RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy. J Trauma Acute Care Surg. 2016 Jan;80(1):95-101. doi: 10.1097/TA.0000000000000867. PMID: 26683395.