Cannot miss / life threats
Cannot miss / life threats
Diagnostic flow — check first
Diagnostic flow — check first
- Trauma → eFAST + upright CXR + ECG; CT if multi-rib or hemodynamic concern.
- Lower ribs (9–12) → assess spleen/liver.
- Upper ribs (1–3) → high-energy mechanism; assess great vessels.
- Atraumatic + ≥40 yo → ECG + troponin before calling it costochondritis.
- Dermatomal pain without rash → consider zoster sine herpete.
Differential diagnosis — checklist
0/15
Check off each diagnosis as you consider it. Tap the name for unique exam, lab/imaging clues, first-line confirmatory test, and management.
Traumatic0/6
Atraumatic / musculoskeletal0/4
Infection / inflammatory / referred0/5
Initial ED workup
Bedside0/5
- Vitals + SpO2
- Inspect for paradoxical motion, ecchymosis, vesicles
- Auscultate lungs, palpate ribs systematically
- ECG if any cardiac suspicion or upper rib trauma
- eFAST if blunt trauma
Labs0/3
- CBC, troponin if cardiac risk
- D-dimer if PE on differential
- Type & screen / coags if significant trauma
Imaging0/3
- Upright PA CXR; CT chest (with IV contrast) if ≥3 fractures, elderly, suspected contusion or vascular injury
- Dedicated rib series if isolated injury
- CT abdomen/pelvis (with IV contrast) if lower-rib fracture
Initial management0/4
- Multimodal analgesia (acetaminophen + NSAID + opioid PRN)
- Incentive spirometry; consider intercostal block, paravertebral block, ESP block
- Chest tube for HTX/PTX
- Admit elderly with ≥2 rib fractures
Pearls / pitfalls
Pearls
- Rib XR is insensitive; CT detects ~3× more fractures.
- Each additional rib fracture in elderly increases mortality ~19% and pneumonia ~27% — admit for pain control.
- Sternal fracture mandates ECG + troponin to rule out blunt cardiac injury.