PANCE Blueprint Musculoskeletal (8%)

Chest/Rib Fractures and Trauma (ReelDx)


85 y/o with Rib pain (4/10) that is worse with deep breathing

Patient will present as → a 29-year-old man presents to the ED with a stab wound to the left chest lateral just below the nipple. The paramedics report that he had been writhing in pain in the ambulance. His blood pressure is 78/50 mmHg, pulse is 125/min, and respirations are 23/min. Tube thoracostomy is performed in the left chest at the fifth intercostal space. About 1,600 ml of blood is evacuated immediately, but the patient continues to lose blood.

What is the definition of a flail chest?
Two separate fractures in three or more consecutive ribs


Illustration of paradoxical breathing caused by an unstable chest wall (flail chest)

Thoracic trauma can be distinguished by the mechanism of injury

Blunt trauma refers to mechanisms causing increased intrathoracic pressure, such as car collisions (the most common cause of thoracic trauma) and falls

  • Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are most frequently involved. Patients usually report inspiratory chest pain and discomfort over the fractured rib or ribs. Physical findings include local tenderness and crepitus over the site of the fracture.
  • Flail chest involves three or more consecutive rib fractures in two or more places, which produce a free-floating, unstable segment of the chest wall
  • Sternal fractures cause pain, tenderness, bruising, and swelling over the fracture site. CPR has also been known to cause thoracic injury
  • Pulmonary contusion resulting from blunt trauma to the chest causing interstitial edema that impairs compliance and gas exchange
  • Ruptured diaphragm - should be considered in patients who sustain a blow to the abdomen and present with dyspnea or respiratory distress
  • Blunt myocardial injury - dysrhythmias, ST changes
  • Pneumothoraces in blunt thoracic trauma are most frequently caused when a fractured rib penetrates the lung parenchyma

Penetrating trauma largely refers to gunshot and stab wounds, occasionally impalement


  • Pain in the chest that gets worse when laughing, coughing, or sneezing, deep inspiration, and overhead activities
  • Difficulty breathing
  • Tenderness, bruising, and swelling

Chest radiography remains the basis for initiating other investigations

  • CT, aortography, bronchoscopy/endoscopy
  • Hemoglobin or hematocrit values and arterial blood gas determinations offer the most useful information for treating these patients
  • ECG
  • Bone scan may be indicated when x-rays are negative and clinical suspicion remains

Treatment involves immediate airway management: intubate early if airway compromise suspected

  • Rib fractures - the majority heal uneventfully with rest, analgesia, cessation of inciting activity for ~4-6 weeks
  • Needle thoracostomy - Use a large bore needle at 2nd intercostal space in the midclavicular line - the best initial step in the management of tension pneumothorax
  • Tube thoracostomy - chest tube at 5th intercostal space in anterior axillary line - next step in management after needle placement in tension pneumothorax
  • Oxygenation - positive pressure ventilation for flail chest
  • Thoracotomy indications - > 1500 ml total blood loss or > 200 ml/hour continued drainage of blood for > 3 hours
  • Surgical repair as needed

osmosis Osmosis

Tension pneumothorax


Tension pneumothorax is characterized by intrapleural pressure that is greater than the atmospheric pressure. It presents with sudden deterioration, hypotension, jugular venous distention, and no breath sounds. It is most commonly due to positive pressure mechanical ventilation.

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Spontaneous pneumothorax


Spontaneous pneumothorax occurs due to the rupture of a subpleural emphysematous bleb that leads to the accumulation of air in the pleural space. It is more common in tall and thin young males.

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Question 1
A 25-year-old male is brought to the ED after having been involved in a head-on motor vehicle accident as an unrestrained passenger. A chest radiograph performed in the ED reveals multiple segmental rib fractures of ribs 3 to 7 on the left side. His respiratory rate is 26/min (labored) with discordant motion on the left side. The most likely diagnosis is:
Cardiac tamponade
See B for explanation
Flail chest
Pulmonary contusion
See B for explanation
Tension pneumothorax
See B for explanation
Question 1 Explanation: 
Flail chest occurs when two or more ribs are segmentally fractured. On physical examination, they will have paradoxical respirations where the affected segment rises with expiration and falls with inspiration. When respiratory failure occurs it is usually in association with an underlying pulmonary contusion. Management typically includes tube thoracostomy for pneumothorax or hemothorax, pain management, pulmonary toileting, and mechanical respiration. Due to altered pulmonary parenchymal fluid dynamics at the point of pulmonary contusion fluid restriction is warranted when possible.
Question 2
A 34-year-old woman presents to the emergency department after a motor vehicle collision. She was the front seat unrestrained driver in a head-on collision at 25 miles per hour. Her temperature is 99°F (37.2°C), blood pressure is 129/66 mmHg, pulse is 127/min, respirations are 16/min, and oxygen saturation is 99% on room air. The primary and secondary survey are performed and are only notable for bruising along her chest wall bilaterally. An initial pelvic radiograph, an electrocardiogram (ECG) are performed and are unremarkable. A chest radiograph is performed and is notable for a sternal fracture and several rib fractures. The patient is given morphine and her heart rate subsequently improves to 80/min. The patient is observed in the emergency department over the next 6 hours and her laboratory values and a repeat ECG return within normal limits. The patient suddenly complains of shortness of breath. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 28/min, and oxygen saturation is 91% on room air. A repeat chest radiograph is performed as seen here. Which of the following is the most likely diagnosis?
Acute respiratory distress syndrome
Acute respiratory distress syndrome would present with sudden and severe shortness of breath secondary to trauma, sepsis, overdose, transfusion, pancreatitis, or aspiration. Patients are typically critically ill with multisystem organ failure and radiography will demonstrate diffuse bilateral involvement with ground glass changes and frank alveolar infiltrates. In the setting of blunt chest trauma in a young patient with the radiography provided, a pulmonary contusion is a more likely diagnosis; however, acute respiratory distress syndrome should certainly be considered.
Cardiac contusion
Cardiac contusion would present after blunt chest trauma and could present with chest pain, shortness of breath, ECG changes, and an elevated troponin. While this patient’s initial trauma may have led to this presentation, her absence of ECG findings, normal troponins, and pulmonary infiltrates on radiology suggest an alternative diagnosis.
Hemothorax would present with pulmonary decompensation after trauma with a unilateral accumulation of radiopaque fluid in the lung rather than diffuse, patchy, and irregular alveolar infiltrates. A chest tube should promptly be placed to drain the hemothorax, and surgery may be needed for persistent or severe bleeding.
Pneumonia presents with a cough, fever, pulmonary crackles, and a lobar consolidation on chest radiography and would not be associated with trauma. Aspiration pneumonia could be seen after trauma; however, it would not manifest hours later with diffuse and bilateral infiltrates.
Pulmonary contusion
Question 2 Explanation: 
This patient is presenting after blunt chest trauma with diffuse and bilateral pulmonary infiltrates with sudden respiratory decompensation suggesting a diagnosis of a pulmonary contusion. A pulmonary contusion is typically seen after blunt trauma to the chest. While it may not be clinically apparent initially, external bruising to the chest wall and rib/sternal fractures can suggest significant trauma that could lead to this diagnosis. Blunt trauma to the lung may initially not be apparent either clinically or on radiography. However, parenchymal bruising can lead to subsequent tachypnea, tachycardia, and hypoxia which can occur hours later. Chest radiography will demonstrate patchy and irregular alveolar infiltrates and arterial blood gas analysis will show hypoxemia. There is no definitive treatment for a pulmonary contusion other than supportive therapy, which includes monitoring the patient, stabilizing their blood pressure, administering oxygen, and intubation if necessary.
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References: Merck Manual · UpToDate

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