May 03, 2019
Motor vehicle, motorcycle and snowmobile accidents cause rib fractures in the elderly population, but far and away the biggest mechanism of injury for rib fracture in older adults involves falls from standing height or from ladders or step stools. Though such fractures are obviously painful, what may not be as clear — on the surface — is that they may also contribute to serious breathing issues, including pneumonia.
According to a study published in the June 2000 issue of the Journal of Trauma: Injury, Infection, and Critical Care, mortality and thoracic morbidity doubles in geriatric patients with rib fracture compared with younger counterparts. A 2004 study published in Journal of the American Geriatrics Society also confirmed increased mortality in older adults sustaining rib fracture.
A variety of factors contribute to rib fracture risk in older adults, such as polypharmacy, chronic health conditions, frailty, increased proneness to dehydration and decreased self-awareness.
"All of these factors are a potentially lethal combination for rib fracture for the elderly individual," says Brian D. Kim, M.D., a trauma surgeon at Mayo Clinic's campus in Rochester, Minnesota, conceding that not all older adults have the same risk factors. "Some elderly adults are extraordinarily healthy and fall clearing snow on a 10-foot ladder, fracturing one or more ribs."
Breathing risks from rib fracture
When patients sustain a rib fracture, pain may preclude normal breathing or secretion clearing. To avoid intensifying discomfort, patients' breathing becomes shallower and they repress coughing, leading to respiratory insufficiency. "You can imagine a set of broken ribs on top of a cough," says Dr. Kim. "Coughing hurts."
Though rib fractures elevate pneumonia risk in all age groups, older adults are at higher risk than those who are younger.
Factors to consider with patients with rib fracture
Dr. Kim explains that in many ways, managing trauma-related rib fracture in an elderly patient — and thus averting respiratory complications such as pneumonia — is more art than science. In other words, individualization and tailoring of care are critical for geriatric patients with this injury.
The following factors are essential to consider when assessing elderly patients presenting with rib fracture:
Spectrum of injury
Older trauma patients sustaining rib fracture may have one broken rib or polytrauma. With four or more ribs fractured, mortality increases significantly, according to the 2004 study.
Patient's age
Dr. Kim points out that one simple rib fracture in a 90-year-old may put the individual at as much risk as would eight rib fractures in a 40-year-old.
Health status before injury
Due to variations in older adults' vigor prior to fracture, a robust 70-year-old with four rib fractures may fare well post-injury, while a 60-year-old with two rib fractures and multiple comorbidities may need transfer to a Level I Trauma Center.
Thinking of a patient in totality — including the above factors and the patient's pulmonary function, mobility and resources — will provide the best care. "A simple rule that patients with three or fewer rib fractures can automatically go home will not do justice to the patient," says Dr. Kim.
Tips for rib fracture management
Dr. Kim advises when an elderly patient arrives with rib fracture, trauma professionals should take the following steps to address the injury and prevent breathing complications:
ABCDEs of trauma
While proceeding through standard trauma ABCDE checkpoints, pay careful attention to the patient's breathing, due to risks from rib fracture. Attempt to avoid tunnel vision or assuming rib fracture is the patient's only injury.
Physical exam
After attending to the ABCDEs, conduct a detailed head-to-toe examination. Particular focus on the chest is appropriate with potential respiratory issues.
Medical history
Consider the patient's health history and how it may impact the patient's triage. History of pulmonary disease, for instance, is a significant risk factor for pneumonia, potentially amplified by rib fracture.
Imaging
Simple chest X-ray is an adjunct for use in trauma evaluation. However, if a patient meets criteria for transfer to a Level I Trauma Center, advanced imaging, such as a CT scan, is not required — the patient should simply be prepared for transfer.
Pain management
Addressing pain early is crucial with rib fracture in the elderly. Though there is no standard formula, pain management needs to be balanced with the patient's condition and injury pattern. Analgesics not only affect pain control, but also facilitate proper breathing. Pain medication, in this scenario, is not just for stasis, but to allow for productive cough and mobilization.
Transfer as appropriate
Determine whether the patient meets transfer criteria, examining physiological and resuscitative needs, injury pattern, and potential for transit safety — specifically, whether the patient's airway can be protected during transport. If a patient falls into the gray zone between keeping locally and transferring, perhaps looking well but with injury, call the potential receiving hospital for decision-making assistance.
"The antenna is definitely up for elderly patients with rib fractures, based on what we know about pulmonary insufficiency," says Dr. Kim. "There's a lot of nuance to geriatric trauma patients — they require thought with respect to how to manage their injuries and triage decisions both on the front and back end of care."
For more information
Bulger EM, et al. Rib fractures in the elderly. The Journal of Trauma: Injury, Infection, and Critical Care. 2000;48:1040.
Stawicki P, et al. Rib fractures in the elderly: A marker of injury severity. Journal of the American Geriatrics Society. 2004;52:805.