sternal fractures and rib fractures

[Painter1]

You have a 60ish male in mva otherwise stable wit direct tenderness to sternum. cxr reveals possible sternal fx. ct reveals minimally displaced sternal fx with small hematoma deep to the sternum.

what do you do? do you consult trauma? do u pain control and send them home?

lets say you have 60ish women come in after fall, complains of left rib pain. two-way cxr is read as normal but patient still in alot of pain.

do you tell the patient she may have rib fx and send her home with pain meds. or do you get rib series OR ct of chest to further evaluate?

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[southerndoc]

First scenario, admit. He has a sternal fracture (which requires a lot of force) with a substernal hematoma. If it expands, it will compress the heart against the spine. That much force could cause traumatic cardiac injury and/or pericardial tamponade. Admit.

Second scenario, I would CT if he/she is in a lot of pain and the chest x-ray is negative. If it's minimal pain, I'll send her home with pain meds and an incentive spirometer.

 

[UnderwaterDoc]

Second scenario, I would CT if he/she is in a lot of pain and the chest x-ray is negative. If it's minimal pain, I'll send her home with pain meds and an incentive spirometer.

I literally did this last night, and she came back today with increased pain and SOB, so we scanned her. Sure enough, she had 2 contiguous rib fractures that the xray didn't pick up, so upstairs she went.

 

[Apollyon]

I literally did this last night, and she came back today with increased pain and SOB, so we scanned her. Sure enough, she had 2 contiguous rib fractures that the xray didn't pick up, so upstairs she went.

A flail segment, or single breaks in 2 adjacent ribs? If it is the latter, why would you admit?

 

[Hamhock]

A flail segment, or single breaks in 2 adjacent ribs? If it is the latter, why would you admit?

Yeah, that was going to be my question.

(unless there was serious baseline pulmonary disease, severe pulmonary contusion affecting respiratory function, or for pain control to limit infxn)

Reminds me of a recent case: 22M no PMHx except the tendency to drink so much he doesn't notice who's driving (I guess better than driving himself) BIBEMS after multiple roll-over - no complaints - exam consistent with mild intox and mild left lateral chest wall pain (far from spleen) and mild shoulder pain - CXR without disease (possible rib fracture seen by rads, not me), pt up and around the ED being a typical 20-something male in the ED on a Sat. night

We were about to discharge (after about three hours in the ED) when the trauma service demanded (including a call from the attending) for a chest CT.

We got it and discharged the patient before trauma even saw the images (we did).

Trauma came down again, chests out, boasting, "See, we were right to get the CT...Thank god you listened to us: there are three rib fractures."

Our response: "Oh, really? We discharged him 30 minutes ago with the same discharge papers".

HH

 

[Birdstrike]

.

 

[Hamhock]

Once you consult a "specialist", who presumably you are consulting because they know more about something than you, you should step out of the way and let them handle what you were unable to handle on your own. If you know more about something than them, you shouldn't consult them and waste their time.

Completely true -- in private practice.

However, the chutes-and-ladders that make an academic program require inter-departmental relations that are less important and more antagonistic than in PP...There is certainly not the 'presumption' that "they know more about something than you"...trauma is consulted on BS in academics all the time...it's an affront to EM...as I have expressed in my rants against ATLS (and ACLS) previously.

This is also why I have yet to respond to the thread/OP regarding the admit for abd serial exams without tenderness:

We don't need trauma's opinion (for most cases).

We consult for admission. no more...in both private practice and academics.

Thanks, HH

 

[UnderwaterDoc]

A flail segment, or single breaks in 2 adjacent ribs? If it is the latter, why would you admit?

The latter. We admitted because she's an 84 YO COPDer with a million other comorbidities who can't take a deep breath to save her life to begin with, and the pain from her fractures was just exacerbating that problem. Her sats were lower, she was working hard to breath, hence the admission.

 

[Apollyon]

The latter. We admitted because she's an 84 YO COPDer with a million other comorbidities who can't take a deep breath to save her life to begin with, and the pain from her fractures was just exacerbating that problem. Her sats were lower, she was working hard to breath, hence the admission.

"See, that is what we call 'relevant additional information' around these parts."

It's not apples and oranges, but more like Fujis vs. red delicious.

 

[Rendar5]

I had the same initial question as apollyon, not realizing that your admitted patient was someone different than the OP's. Elderly with rib fx's = badness.

 

[crewmaster1]

Once you consult a "specialist", who presumably you are consulting because they know more about something than you, you should step out of the way and let them handle what you were unable to handle on your own. If you know more about something than them, you shouldn't consult them and waste their time. Don't do this in private practice or you'll lose all clout in about 30 seconds with any consultant you pull this on.

Yeah, it's all fun an games when it's some knuckle dragging, mouth breather, toolbox surgery intern you want to piss off, just don't do it when you go out on your own.

Have you heard the joke:

"How many doctors does it take to make a clinically irrelevant diagnosis?"

100% agree. I remember how much residency had much more or a turf war and these feelings of us vs them. In the real community world, it is much different. This crap never happens. Your consultants are there to help you and you only consult them when needed. the question with the above scenario is why did you consult them in the first place? Stable trauma with a neg CXR? who the hell needs trauma to figure that out?

 

[UnderwaterDoc]

"See, that is what we call 'relevant additional information' around these parts."

It's not apples and oranges, but more like Fujis vs. red delicious.

Noted 🙂

 

[Painter1]

turns out multiple rib fractures carry significant morbidity especially in order patients.

three rib fractures at my institution warrants a trauma consult via our trauma consult criteria and an admission if the patient is older.

with that said, i was trained in residency to not get a rib series because it wouldn't change management; that rib fxs is a clinical diagnosis. and that therefore, a cxr would suffice looking for pneumo or hemothorax.

well, in the case scenario above with the older lady with fall and rib tenderness and normal cxr, she returned several days later with worsening pain and sob. a rib series and ct chest revealed 3 rib fxs (no flail chest) and subsequent hemothorax. hemothorax must've developed over the couple days.

trauma was up-in-arms (playing monday quarterback) noting the patient should've got furhter imaging and admitted to their service after a consult based on the patient having three rib fractures.

are you guys getting rib series?

 

[tkim]

are you guys getting rib series?

I do if I think there might be multiple fx based on physical exam. Otherwise it's percs and spirometry.

 

[southerndoc]

Once you consult a "specialist", who presumably you are consulting because they know more about something than you, you should step out of the way and let them handle what you were unable to handle on your own. If you know more about something than them, you shouldn't consult them and waste their time. Don't do this in private practice or you'll lose all clout in about 30 seconds with any consultant you pull this on.

I agree. If you consult someone, you shouldn't just do it to CYA and not listen to them. It actually increases your liability if you ignore their advice.

In private practice, you don't want to burn your bridges.

 

[southerndoc]

trauma was up-in-arms (playing monday quarterback) noting the patient should've got furhter imaging and admitted to their service after a consult based on the patient having three rib fractures.

are you guys getting rib series?

Yes, I routinely get rib series (which includes a PA chest). Does it change management? Rarely, but if you see a definite fracture, then you can tell the patient. If it doesn't show a fracture, I tell the patient I think they still could have a fracture that didn't show up on x-ray. It prevents the "I came back and got a CT and the doc that saw me the first time missed 2 rib fractures" complaints.

I'm glad I work in an institution where the consultants/admitting teams don't sit around just Monday morning quarterbacking all the time. As an administrator, I review cases where there is concern. I have never gotten a call from a surgeon, cardiologist, etc. saying "this guy is a total ***** and this patient was completely mismanaged." Every time it's been "hey, can you review this and see if it's appropriate for emergency department care?"

 

[Cerberus]

I never get a rib series. If I'm concerned enough about chest pain/difficulty breathing/abnormal VS s/p trauma and I'm not seeing fractures on the CXR I'll go straight to CT.