Predicts adverse pulmonary outcomes from rib fracture
Audience: PRACTITIONER
Published by EVAL Foundation
Revision 2 · Published August 1, 2024
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.
| Variable | Points |
| ≥ 6 fractures | No 0 Yes 1 |
| Bilateral fractures | No 0 Yes 1 |
| Flail chest | No 0 Yes 1 |
| ≥ 3 severely (bicortical) displaced fractures | No 0 Yes 1 |
| First rib fracture | No 0 Yes 1 |
| ≥ 1 fracture in all three anatomic areas (anterior, lateral and posterior) | No 0 Yes 1 |
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
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Inclusion Criteria
Apply this decision aid in patients with confirmed rib fractures on imaging.
Current: Revision 2
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