What should be assessed in a patient with rib pain after a fall in an urgent care setting?

Assessment of Rib Pain After a Fall in Urgent Care

A thorough assessment for a patient with rib pain after a fall should include chest radiography as the initial imaging test, focused physical examination for complications, and evaluation for risk factors that may indicate more serious injury. 1

Initial Physical Assessment

• Pain Assessment:

  • Evaluate pain severity at rest and with movement (movement-evoked pain scores are consistently higher and better correlate with functional limitations) 2
  • Document location and radiation of pain
  • Note aggravating factors (deep breathing, coughing, movement)

• Chest Wall Examination:

  • Inspect for bruising, swelling, or deformity
  • Palpate for point tenderness along ribs, costal margins, and costochondral junctions
  • Assess for crepitus (subcutaneous emphysema) which is a significant risk factor for delayed pneumothorax 3
  • Check for paradoxical chest wall movement (flail chest)

• Respiratory Assessment:

  • Respiratory rate and pattern
  • Oxygen saturation
  • Auscultate for diminished breath sounds, crackles, or wheezes
  • Assess for signs of respiratory distress or splinting (limited chest expansion)

Imaging Studies

• Chest Radiography:

  • Should be the initial imaging test for rib pain after trauma 1, 4
  • While chest X-rays detect only about 50% of rib fractures, they are valuable for identifying complications such as pneumothorax, hemothorax, and pulmonary contusion 4
  • Standard posteroanterior (PA) and lateral views are recommended

• Dedicated Rib Views:

  • May be helpful for focal chest wall pain detected on physical examination 1
  • Consider using radio-opaque skin markers placed at the site of maximum tenderness
  • Note that while more sensitive than chest X-rays for detecting fractures, rib series rarely change clinical management 1, 4

• Point-of-Care Ultrasound:

  • Can detect rib fractures missed on chest radiography (29% of cases with negative X-rays) 1
  • Particularly useful for costochondral fractures 1
  • Limitations include difficulty visualizing posterior fractures and reduced effectiveness in patients with large body habitus 1

Risk Assessment

• High-Risk Features Requiring Closer Monitoring:

  • Advanced age (each rib fracture increases pneumonia risk by 27% and mortality by 19% in elderly patients) 5
  • Multiple rib fractures (≥3)
  • Pre-existing pulmonary disease
  • Anticoagulant use
  • Subcutaneous emphysema (strongest predictor of delayed pneumothorax) 3

• Clinical Prediction Rules for Intra-abdominal Injury:

  • Assess for costal margin tenderness, which is a predictor of intra-abdominal injury 1
  • Other risk factors include: abdominal tenderness, hematuria (≥25 RBCs/HPF), abnormal chest radiograph, Glasgow Coma Scale <14, femur fracture, and hematocrit <30% 1

Complications to Rule Out

• Immediate Complications:

  • Pneumothorax or hemothorax
  • Pulmonary contusion
  • Flail chest
  • Intra-abdominal injuries (especially with lower rib fractures)

• Delayed Complications:

  • Delayed pneumothorax (most common in first 48 hours) 3
  • Atelectasis and pneumonia (due to pain-induced splinting)
  • Rare complications like traumatic chylothorax (can present with milky pleural fluid 2-10 days after injury) 6

Pain Management Assessment

• Evaluate pain control needs based on movement-evoked pain rather than just resting pain 2
• Consider respiratory function (SpO2/FiO2 ratio) when assessing adequacy of pain control 7
• Assess patient's ability to:
  • Take deep breaths
  • Cough effectively
  • Clear secretions
  • Perform incentive spirometry

Follow-up Planning

• For patients with uncomplicated rib fractures being discharged:
  • Ensure adequate pain control
  • Provide clear return precautions (worsening pain, shortness of breath, fever)
  • Schedule appropriate follow-up based on injury severity
• For patients with risk factors for complications:
  • Consider observation, especially with subcutaneous emphysema due to high risk of delayed pneumothorax 3

Common Pitfalls to Avoid

• Relying solely on chest X-ray to rule out rib fractures (misses approximately 50% of fractures) 4
• Failing to assess for intra-abdominal injuries with lower rib fractures
• Underestimating pain severity by only assessing pain at rest rather than with movement 2
• Missing subcutaneous emphysema, which is the strongest predictor of delayed pneumothorax 3
• Inadequate pain control leading to respiratory compromise and complications

Remember that the primary goal of assessment is not just to diagnose rib fractures but to identify potentially life-threatening complications and ensure adequate pain control to prevent respiratory compromise.