Management of Rib Depression Over the Liver
In patients with rib depression over the liver from blunt trauma, perform contrast-enhanced CT to evaluate for hepatic injury and associated intra-abdominal injuries, as lower rib fractures with multiple injuries are associated with abdominal organ injury in 67% of cases, even when physical examination is normal. 1
Initial Assessment and Risk Stratification
The clinical context determines management urgency:
High-energy mechanism or multiple injuries: These patients require immediate contrast-enhanced CT regardless of physical examination findings, as lower rib fractures (ribs 7-12) are associated with abdominal organ injury in 67% of patients with multiple injuries 1
Hemodynamically unstable patients: If hepatic injury is confirmed and the patient is unstable, proceed directly to operative management with manual compression and hepatic packing as first-line damage control, avoiding time-consuming imaging 2, 3
Low-energy mechanism with normal examination: In isolated trauma with stable vital signs and no clinical evidence of complicated injury (pneumothorax, hemothorax, flail chest), imaging may be deferred as the negative predictive value of physical examination for abdominal injury approaches 100% 1
Diagnostic Imaging Strategy
Contrast-enhanced CT is the definitive imaging modality when hepatic injury is suspected:
The absence of rib fractures does not rule out hepatic injury—studies show no significant association between right-sided lower rib fractures and hepatic laceration in matched trauma patients 1
Bedside ultrasound can identify hepatic injury, hematoma, or biliary pathology when transport for CT poses infection control concerns or patient instability 1
Plain radiographs have limited utility, detecting rib fractures in only 46% of cases and providing no information about hepatic injury 1
Management Based on Findings
If Hepatic Injury is Identified:
Hemodynamically stable patients with solid organ injury can be managed non-operatively with close monitoring, serial hemoglobin measurements, and restrictive transfusion strategy (target hemoglobin 7-9 g/dL) 3
Hemodynamically unstable patients require:
- Immediate operative intervention with manual compression and hepatic packing as first-line technique 2, 3
- Simultaneous massive transfusion protocol to maintain organ perfusion 2, 3
- Pringle maneuver (hepatic pedicle clamping) alongside packing 2
- Post-operative angioembolization for persistent arterial bleeding 2, 3
- Temporary abdominal closure with synthetic mesh to prevent abdominal compartment syndrome 2, 3
If No Hepatic Injury but Isolated Rib Pain:
Consider painful rib syndrome (slipping rib syndrome) if the patient presents with:
- Pain in the lower chest or upper abdomen with a tender spot on the costal margin 4
- Reproduction of pain on pressing the tender spot 4
- This is a clinical diagnosis requiring no investigation and accounts for 3% of general medical referrals 4
Critical Pitfalls to Avoid
Do not rely on physical examination alone in patients with multiple injuries and lower rib fractures—contrast-enhanced CT is indicated even with normal examination 1
Do not assume rib fractures predict hepatic injury—the correlation is weak, and hepatic injury can occur with intact ribs due to direct impact mechanisms 1, 5
Do not miss diaphragmatic injuries—rib fractures with minor liver injuries are independently associated with diaphragmatic injury (odds ratio 3.26), with 21% incidence in this population 6
Avoid extensive investigation in stable patients with isolated painful rib syndrome, as this leads to unnecessary procedures including non-curative cholecystectomies in some cases 4