Fractures of the ribs and pelvis

EBM Guidelines
12.8.2019

Essentials

  • Fractures of the ribs and pelvis vary from very mild fractures which can be treated conservatively to life-threatening fractures.
    • Unstable rib fractures may be accompanied by profuse bleeding, pneumothorax and breathing difficulties.
    • A pelvic fracture may occur due to a high-energy trauma, leading to severe blood loss, or due to a low-energy trauma; the latter occurs particularly in the elderly (fragility fracture) as the bone structure becomes weaker (osteroporosis).
    • Posterior pelvic ring fractures (sacral fractures and sacroiliac luxation) are associated with a risk of nerve injury.
    • The fracture itself does not say anything about the amount or quality of any damage to the viscera.
    • The whole injury entity must be identified in order to choose the correct line of treatment.
  • 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, away from the site of the fracture (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, the patient can breathe well despite the pain, and the clinical examination does not reveal any other alarming signs. However, a chest x-ray should be taken if it is necessary to exclude haemothorax or pneumothorax and in cases where multiple rib fractures are suspected (picture «Clavicle fracture, rib fractures and haemothorax»1).

Treatment

  • A low-energy uncomplicated fracture of one rib can usually be treated at an outpatient clinic. The patient should not hesitate to contact the emergency department again if the symptoms get worse.
  • In multiple rib fractures, follow-up observation and treatment require observation or hospitalization in the initial phase.
    • In fractures of two or more ribs, the energy involved in the injury will have 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 be referred for treatment at hospital even if no rib fractures have been confirmed.
  • In patients with flail chest, respiratory support is needed (if conscious, using a CPAP mask; if unconscious, by intubation and ventilation).
  • Pneumothorax «Pneumothorax»1 and haemothorax should be treated with a chest tube placed by tunnelling. Acute tension pneumothorax should be released with the thickest venous cannula if no other equipment is at hand. In an emergency situation the decision about thoracocentesis must be made based on auscultation findings, without waiting for chest x-ray. Introduce the cannula on the side with absent breath sounds.
    • If symmetrical breath sounds are heard from the lungs but the patient is cyanotic and in a poor condition, with bulging jugular veins, the patient may be suffering from cardiac tamponade.
    • There is no time to lose if the patient is tachycardic, breathing shallowly, anxious, has a greyish skin colour and is clearly in a bad state.
  • Injection of bupivacaine (3–5 ml under the lower costal margin; video «Diagnosis of rib fracture and intercostal nerve block»1) will give pain relief for several hours and can be repeated if necessary.
  • A rib fracture is often disturbingly painful at first. The pain will continue for the next few weeks, subsiding gradually and controllable with analgesics.
  • The patient should be advised to return to the emergency department immediately if they experience breathing difficulties again after discharge.
  • Strapping of the thorax may be used to alleviate pain caused by chest wall movement. The strapping must not impede respiratory function.
    • The bandage used for strapping should be of adhesive-free self-adhering material.
  • A follow-up chest x-ray should be taken of patients with fractures of two or more ribs even if the first x-ray showed normal lungs. If pneumothorax or haemothorax was diagnosed, radiography should be repeated 1(–2) times per 24 hours until a convincing decrease in the size of the lesion is observed. Until then, the patient should be treated in the hospital.
  • In the elderly, sputum retention may lead to chest infection. This should be prevented by providing adequate pain relief and by use of deep breathing exercises (blowing into a bottle). Pneumonia should be suspected immediately should signs of an infection appear.

Fractures of the pelvis

Table 1. Fractures of the pelvis
Type of fracturePathogenetic mechanismTreatment
AvulsionMuscle insertion tears off with an avulsion of a bone fragment (athletes)Conservative treatment is often sufficient.
Ramus fracture (single, stable, no sacral fracture)Typically following a fall or sideways impactPain relief and early mobilization
Fracture of the pelvic ring at several points, sacral fractures, sacroiliac luxationHigh-energy injury (traffic accident, fall from a height, fall); an injury of lower energy is sufficient to cause these in a patient with osteporosisUsually surgical fixation of the fracture, milder injuries (partially 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 emergency assessment and specialized care

High energy injuries of the pelvis

  • It is important to recognize the possibility of bleedings and neurological damage.
  • 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.
  • Fractures of the pelvis or acetabulum require a thorough clinical examination, adequate imaging (CT) and fluid therapy that is adjusted to the patient profile, and, as required, bleeding management (embolization, surgery) and intensive care.

Low-energy pelvic fractures

  • A pelvic fracture or a fracture of the acetabulum may result from a fall, particularly in individuals whose bone substance has become brittle due to osteoporosis (fragility fracture).
  • A fall may be associated with a sacral fracture, which, in a transverse form easily causes nerve root damage in the cauda equina area.
  • X-ray examination of the pelvis should include both an AP projection and, when sacral fracture is suspected, a lateral view of the sacrum.
  • Bone interfaces should be carefully studied in the x-rays. A CT scan is often needed for the final assessment of the fracture type and required line of treatment.
  • A patient with an undisplaced (stable) fracture of the pubic ramus needs no bed rest. Mobility and weight bearing should be allowed within the limits of pain; the treatment can be carried out on a primary care in-patient ward.
    • Antithrombotic prophylaxis can be initiated after 24 hours when the risk of bleeding has subsided.
    • Fractures of the acetabulum are mainly treated surgically, allowing early mobilization.
    • Verify that there is no transverse fracture or vertical instable fracture in the sacrum.

Fracture of the sacral or coccygeal bones

  • Result from falling over or from a height (e.g. falling off a chair in sitting position)
  • A sacral fracture may be vertical, bilateral vertical, horizontal, or a combination of these (H type fracture).
  • A transverse sacral fracture may be associated with cauda symptoms as a result of dislocation.
  • An x-ray is important in the initial phase of the diagnostic workup (N.B.! lateral views of the sacral and coccygeal bones, which are not visible in lateral views of the pelvic spine).
  • A transverse sacral fracture is difficult to distinguish clinically from a fracture of the coccygeal bone.
  • Local tenderness may be established through a careful examination. Subcutaneous haematomas may be found in the gluteal region.
  • Surgical treatment is often needed for sacral fractures (instability or problems with nerves).
  • Treatment of a fracture in the coccygeal apex consists of pain relief and the provision of a suitable seat. In chronic cases, removal of the fracture fragment may be considered.