Fractures of the ribs and pelvis

EBM Guidelines
22.4.2013

Essentials

  • Fractures involving the ribs and pelvis may only require conservative treatment or they may be more serious:
    • unstable rib fractures may be accompanied by profuse bleeding, pneumothorax and breathing difficulties
    • a fractured pelvis may lead to severe blood loss.
  • Recognize tension pneumothorax in a trauma patient, see «Pneumothorax»1.

Rib fractures

Diagnosis

  • A diagnosis can be made clinically, i.e. the site of the fracture is tender both on direct palpation and when pressure is applied to the fractured rib from the back (video «Diagnosis of rib fracture and intercostal nerve block»1).
  • It is important to recognize whether only one or several ribs are fractured. In multiple rib fractures the risk of complications is significantly increased.
  • Auscultate the lungs; if the finding is asymmetrical, suspect pneumothorax.
  • A chest x-ray is not necessary provided that the energy involved in the injury was low, there are no abnormal findings on auscultation and the clinical examination does not reveal any other alarming signs. However, chest x-ray should be readily taken to exclude haemothorax or pneumothorax if there are grounds to suspect these, and in cases where multiple rib fractures are suspected (picture «Clavicle fracture, rib fractures and haemothorax»1).

Treatment

  • Fracture of one rib can usually be treated at an outpatient clinic. In multiple rib fractures, follow-up observation at the treatment unit is warranted in the initial phase.
    • In fractures of two or more ribs, the energy involved in the injury has been so high that pleural rupture and development of pneumothorax are possible. The risk of bleeding is increased as well.
  • If clinical examination reveals widespread tenderness around the injury site and the energy involved was significant, the patient should readily be referred for observation at hospital even if no rib fractures have been confirmed.
  • Injection of bupivacaine (3–5 ml under the lower rib edge; video «Diagnosis of rib fracture and intercostal nerve block»1) will give pain relief for several hours, and can be repeated if necessary. If injecting the fractured rib does not offer pain relief, an intact rib on both sides of the fractured rib may also be injected.
  • A rib fracture will be markedly painful for three days. The pain will then ease and persists for three weeks but is controllable with analgesics.
  • A control chest x-ray should be readily taken of patients with fractures of two or more ribs. If pneumothorax or haemothorax was diagnosed, radiography is repeated 1(–2) times per 24 hours until a convincing decrease in the size of the lesion is observed.
  • The patient should be advised to return to the clinic if he/she experiences breathing difficulties.
  • Strapping of the thorax may be applied if necessary to alleviate pain caused by chest wall movement. The strapping must not impede respiratory function. Adhesive strapping is not recommended as it may irritate the skin and its removal is painful. The bandage used for strapping should be of glueless self-adhesive material. Usually no strapping is required.
  • In the elderly, sputum retention may lead to chest infection. This should be prevented by providing adequate pain relief. Pneumonia should be suspected on the emergence of signs of an infection.
  • Flail chest is strapped and the patient is supported with a vacuum mattress during transportation; respiratory function has to be secured.
  • Pneumothorax «Pneumothorax»1 and haemothorax are treated with a chest tube. Acute tension pneumothorax is released with a thick needle intended for intravenous use (Viggo®) if no other equipment is at hand. The decision about thoracocentesis is in an emergency situation to be based on auscultation findings, without waiting for chest x-ray.
    • There is no time to lose if the patient is tachycardic, breathes shallowly, is anxious, has greyish skin colour and is clearly in a bad condition!

Fractures of the pelvis

High energy injuries of the pelvis

  • A complicated unstable fracture of the pelvis may lead to the loss of 1–3 litres of blood, and intravenous infusion should therefore be provided during transport.
  • If the patient has an unstable fracture of the pelvis, a vacuum mattress is used during transportation to reduce bleeding and pain. Alternatively, the pelvis can be stabilized with a body drape to reduce massive bleeding.

Fracture of the pelvis in an elderly patient

  • Fractures of the acetabular floor following a fall are common in elderly patients.
  • An x-ray examination of the pelvis should include both an AP projection and a lateral view of the affected side.
  • The edges of the bones and the acetabular floor must be carefully studied from the x-rays. Are any fissures or displacement evident?
  • A patient with an undisplaced (stable) fracture of the pubic ramus needs no immobilization. Mobility and weight bear are allowed within the limits of pain; the treatment can be carried out on a general hospital ward (injuries caused by a fall).
  • Antithrombotic prophylaxis is usually initiated after 24 hours when the risk of bleeding has subsided.
Table 1. Fractures of the pelvis
Type of fracturePrevalenceTreatment
AvulsionIn athletes: muscle contraction leads to avulsion of a bone fragmentInternal fixation sometimes required, e.g. with screws
Ramus fracture (single, stable)Typically in an elderly person following a fallPain relief and early mobilization
The pelvic ring fractured at several pointsHigher-energy injury (traffic accident, fall from a height, fall)Usually surgical fixation, milder injuries (stable) treated conservatively
AcetabulumFall (osteoporosis!), traffic accident, fall from a height; fracture of the acetabular floor in the elderly.A dislocated fracture or a dislocated hip joint need immediate treatment, completely undisplaced cases treated conservatively

Fracture of the coccyx

  • After a fall or childbirth
  • A very painful fracture
  • An x-ray is not necessary in the initial phase after a minor injury, but radiography is advisable if the injury was significant (e.g. falling from a greater height and landing on the coccyx). Such an injury may, besides a fracture of the coccyx, lead to a sacral fracture, which requires assessment at hospital (cauda symptoms possible).
  • Treatment of a fracture in the coccygeal apex consists of pain relief and the provision of a suitable seat. In chronicized cases, removal of the fracture fragment may be considered.
    • Local anaesthesia is usually not used in the acute phase.