Severity of Intrathoracic Injuries Associated with First Rib Fractures John E. Albers, M.D., Ranjit K. Rath, M.D., Richard S. Glaser, M.D., and P. K. Poddar, M.D. ABSTRACT The benign condition of isolated first rib fracture is compared with the severity of intrathoracic injuries resulting from first rib fracture associated with multiple rib injuries. Seventy-five patients with 90 first rib fractures were divided into two groups. Group 1 (n = 13) included those with isolated first rib fractures and Group 2 (n = 62), those with first rib fractures associated with multiple rib injuries. In Group 1 patients, intrathoracic injuries were mild with no major vascular injuries. Conversely, Group 2 patients sustained severe intrathoracic injury, 58% of them with aortic injury. Stress is placed on early diagnosis, assigning of priority to associated injuries, and early operative intervention. The significance of first rib fracture and its association with intrathoracic injuries has received renewed interest in the surgical literature within the last few years [l-51. In general, the clinical implications of isolated first rib fracture have a different connotation from those of multiple rib fractures. Since the first rib is situated deep in the shoulder girdle and is protected by heavy musculature, it has been assumed that a heavy force is necessary for it to fracture [6] with resultant injury to other structures. When fractured, the first rib can cause severe injury because of its proximity to major vessels, nerves, and lung. The use of routine angiography has been recommended in some centers [5, 7, 81 due to the relationship of the fractured first rib to major vascular structures. In a review of injuries associated with isolated first rib fractures compared with combined first rib fracture plus multiple From the Division of Thoracic-Cardiovascular Surgery, Good Samaritan Hospital, Cincinnati, OH. Presented at the 28th Annual Meeting of the Southern Thoracic Surgical Association, Palm Beach, FL, Nov 5-7, 1981. Address reprint requests to Dr. Albers, 2350 Auburn Ave, Cincinnati, OH 45219. rib injuries, the clinical implications of the severity of injury are different. The necessity for routine angiography in the management of the majority of patients with isolated first rib fractures is not indicated unless other clinical manifestations of vascular trauma are present. Conversely, the incidence of major trauma to vascular, neurological, pulmonary, and other systems in combined first and other rib injuries is common, ranging as high as 58% for aortic injury in this review. Because of the high incidence of injury to major intrathoracic and other systems, the management of these problems is difficult and necessitates astute, efficient diagnosis, proper evaluation of the injuries, and early operative intervention. The purpose of this paper is to demonstrate the benign condition of isolated first rib fractures compared with the severity of intrathoracic injuries resulting from first rib fractures associated with multiple rib injuries. Material and Methods Seventy-five patients with 90 first rib fractures (15 bilateral) were collected from the Thoracic- Cardiovascular Service of Good Samaritan Hospital and the records of the Hamilton County Coroner s Office in Cincinnati, Ohio. Patients were categorized into two groups: Group 1 (n = 13) consisted of patients with unilateral isolated first rib fracture and Group 2 (n = 62), patients with first rib fracture in association with multiple rib fractures. The patients ranged from 12 to 88 years old. There were 44 male (59%) and 31 female (41%) patients. In both groups the mechanism of injury was most frequently caused by vehicular accident (68%). A traumatic fall was the next most frequent mode of injury (13%), and 46% of these injuries occurred in Group 1 patients. The intrathoracic injuries associated with Group 1 are collated in Table 1 and Group 2, in Table 2. The severity of pulmonary contusion 614 0003-4975/82/060614-05$01.25 @ 1981 by The Society of Thoracic Surgeons
615 Albers et al: Intrathoracic Injuries Associated with First Rib Fractures Table 1. Associated Pulmonary Injuries with Isolated First Rib Fracture in Group 1 (N = 13) Type Patients Percent Pulmonary contusion Mild 9 69.2 Moderate 4 30.8 Severe 0 0 Pneumo thorax 1 7.7 Widened mediastinum" 1 7.7 anonnal aortogram. Table 2. Associated Pulmonary Injuries with First Rib Fracture Combined with Other Rib Injuries in Group 2 (N = 62) Type Patients Percent Pulmonary contusion Mild 7 11.3 Moderate 27 43.5 Severe 28 45.2 Pneumo thorax 34 54.8 Hem0 thorax 34 54.8 Bronchial rupture 1 1.6 was divided into three levels: mild-minimal roentgenographic changes with normal respiratory rate and motion with normal blood gases; moderate-minimal roentgenographic changes with tachypnea greater than 22 breaths per minute and requiring oxygen through a mask or cannula to maintain comfort and adequate blood gases; and severe-marked roentgenographic changes and requiring intubation with mechanical ventilation to maintain effective exchange. Other associated injuries not of a pulmonary nature are shown in Table 3. If there was only one system involved, the patient was seen by the Thoracic-Cardiovascular Service. When more than one system was injured, the patient was seen by the Multiple Trauma Service at Good Samaritan Hospital. There the patient's condition was stabilized, and appropriate studies were performed or immediate operation was undertaken if necessary. All subspecialty services, including anesthesia, are available in the hospital 24 hours a day. Results In the group of patients with isolated first rib fracture, the mechanism of injury frequently was a fall (46%) that occurred at home to patients in the seventh to ninth decade of life (Table 4). The associated intrathoracic injuries in this subgroup were benign, and the patients quickly recovered, having an average hospital stay of 3.5 days. Two patients had injuries that were not thoracic in nature: a fractured patella in 1 and an acromioclavicular separation in the other. The mode of injury in these patients gives credence to the fact that minimal trauma can cause fracture of the first rib, as Alderson [91 reported in 1947 (37 patients with first rib fracture in whom no history of trauma was obtained), and supports the view that these fractures may be caused by stress of muscle pull or simply by posterior displacement of the clavicle from a blow or fall. Auto accidents were the next most frequent mode of injury in Group 1, and with but one exception, the injuries were minor. The exception was a patient who sustained a severe head Table 3. Associated Nonpulmonary Intrathoracic Injuries Group 1 Group 2 (N = 13) Percent (N = 62) Percent Widened mediastinum 1" 7 31 50.0 Aortic injury 0 0 36 58.1 Bronchial plexus injury 0 0 2 3.2 Cervical vertebral injury 0 0 7 11.3 Spinal cord injury 0 0 1 1.6 "Normal aortogram.
616 The Annals of Thoracic Surgery Vol 33 No 6 June 1982 Table 4. Mechanism of lnjury in Group 1 (N = 13) Age Avg. Hospitalization Mechanism Patients Percent (Yr) (days) Fall at home 6 46.2 63-88 3.5 Auto accident 4 30.8 12-48 7.2a Struck by heavy object 1 7.7 21 4.0 (22.68 kg) Dive into shallow water 1 7.7 25 29.0 Struck by auto 1 7.7 12 11.0 Includes 1 patient with head injury and 19 days of hospitalization. Table 5. Multisystem lnjuries in Patients in Group 2 Who Died (N = 36) System Injury Cardiac 9 Vascular (aorta) 34 Neurological 15 Intraabdominal Liver 11 Spleen 6 Kidney 1 Gastrointestinal 5 Maxillof acial 3 Patients Table 6. Multisystem lnjuries in Patients in Group 2 Who Had No Aortic lnjury and Survived (N = 26) System Injury Pulmonary 26 Skeletal 17 Neurological 9 Maxillof acial 3 Intraabdominal 5 Liver 3 Spleen 2 Kidney 3 Patients injury which required 19 days of hospitalization. Chest roentgenograms demonstrated that besides the fracture of the first rib, the patient also had a widened mediastinum with obliteration of the aortic knob. Diagnostic aortography revealed no vascular injury, and in follow-up roentgenograms, no abnormalities were noted. In Group 2, the mechanism of injury in all but 5 patients was due to vehicular accident; 50 were in an automobile accident and 7, a motorcycle accident. The severity of injury in this group is shown in the high mortality of 36 patients (58%) (Table 5). Thirty-four of these 36 patients (94.4%) sustained injury to the aorta as well as to other organ systems, with 27 of them (79.4%) being dead on arrival at the hospital. Rupture of the aorta was the chief cause of death although other injuries were certainly contributing factors. Two deaths in this group were not associated with aortic or major vessel injury but were due to irreversible massive in- tracerebral injury, with death occurring from 12 hours to 10 days after injury. Two patients with rupture of the aorta had associated hepatic, skeletal, and splenic injuries and underwent immediate operation using a two-team surgical approach. Both survived. The remaining 24 survivors (38.7%) in Group 2 did not have aortic injury but all had multisystem injuries, as seen in Table 6. The injuries were assigned priority after stabilization of the patient s condition, and through a multidisciplinary approach, appropriate diagnostic and therapeutic modalities were performed. Comment A review of the literature [l-81 makes it apparent that isolated fracture of the first rib is not as uncommon as once believed. It can occur frequently from minor trauma, such as a fall at home, or from a minor blow. Most often it is associated with minor intrathoracic injury,
617 Albers et al: Intrathoracic Injuries Associated with First Rib Fractures such as mild pulmonary contusion, pneumothorax, or hemothorax. Although injuries to the neurovascular structures do occur in isolated fracture of the first rib [I, 7, 103, they are not common (none in 13 patients in this series). However, the clinician has to be alert to the possibility. In our institution, routine arteriography for patients with isolated first rib fracture is not recommended and should be done only when other signs are present. Conversely, fracture of the first rib in association with other rib injuries connotes major trauma; more than half of the patients in this group (58% or 36 patients) sustained injury to the aorta. We advocate arteriography in all such patients because of the high incidence of major vascular injury. In 4 patients, the injury to the aorta occurred in multiple areas. Two patients had lacerations of the ascending aorta, 2 had transection just above the level of the diaphragm, and 28 sustained the injury at the level of the left subclavian artery or the area of the ligamentum arteriosum (Figure). These sites of predilection of injury are in agreement with other reports. Of the 2 patients with aortic injury who survived in Group 2, both had associated splenic and hepatic injury along with severe pulmonary contusions and left-sided hemopneumothorax. It is this type of patient who requires the multidisciplinary approach and the establishment of priority for the injuries. Our approach is to stabilize the patient s condition as quickly as possible in this order: (1) endotracheal intubation with mechanical ventilation; (2) insertion of a thoracotomy tube if tension pneumothorax or large hemothorax is present; (3) blood, colloid, or crystalloid replacement; (4) maintenance of blood pressure at higher than 80 mm Hg systolic if possible, using vasopressors infrequently; (5) insertion of a Foley catheter; (6) quick physical evaluation; (7) peritoneal lavage; (8) immediate angiography; and (9) operative intervention. In patients with injury to the descending aorta associated with intraabdominal injury, the patient is placed on the operating table in the left lateral thoracotomy position with the lower torso angled at approximately 45 degrees. The entire chest and abdomen are prepared and Sites of aortic injury in 36 patients. Four had multiple sites of injury. draped. If the chest injury is comparatively stable, then the abdominal injury takes precedence over repair of the aorta. If the chest injury is not stable, then the aortic injury takes precedence, with the knowledge that repair of the aorta may precipitate further intraabdominal hemorrhage. Because of the unstable condition of the 2 survivors with aortic injury, simultaneous left lateral thoracotomy and midline abdominal incisions were made. Control of the thoracic aorta was obtained while splenectomy and partial hepatectomy were performed, following which the aorta was resected with insertion of a graft. In general, because of the stability of the aortic injury which can be determined through evaluation of the aortogram, chest roentgenogram, and physical examination, we believe that
618 The Annals of Thoracic Surgery Vol 33 No 6 June 1982 the order in which injuries should be treated is: (1) neurological-subdural or extradural hematoma with progressive neurological signs; (2) intraabdominal injuries with massive hemorrhage-(a) liver, (b) spleen, (c) ruptured intestine, (d) major venous hemorrhage and lacerated inferior vena cava or iliac veins; (3) symptoms of spinal cord compression, which are progressing; and (4) rupture of the main bronchus or trachea, giving rise to inability to maintain ventilation. These injuries can be treated successfully followed by repair of the aortic injury under the same anesthetic or may be treated simultaneously through the double surgical-team approach as already described. Skeletal, maxillofacial, and urological problems are handled best after repair of the aortic injury. A sheared renal pedicle can be repaired after the aortic injury when the retroperitoneal space is intact, due to its tamponading effect. In certain instances this injury may take precedence over repair of the aorta or must be done concomitantly. The importance of early diagnosis of aortic injury in patients such as ours in Group 2 cannot be stressed enough. Of the 7 patients who survived 2 to 24 hours after arrival at outlying hospital emergency rooms, in retrospect, 5 could possibly have survived with early diagnosis, assigning of precedence to the injuries, and operative intervention. In these patients, the associated injuries to other systems were not considered lethal, and the cause of death was unrecognized injury to the thoracic aorta. Associated intrathoracic injuries to the lung parenchyma and the tracheobronchial tree require intensive therapy with mechanical ventilation. Tracheostomy was required in 15% of these patients because of the necessity for prolonged ventilation and the associated chest instability. The routine use of physiological monitoring by insertion of a radial or brachial artery catheter, central venous pressure line, and a Swan-Ganz catheter has been a great aid in the postoperative management-of these patients. In summary, isolated first rib fractures are not uncommon and, in general, have minor associated intrathoracic injuries with a benign course. Routine angiography is not necessary. However, first rib fractures combined with multiple rib injuries connote major intrathoracic and extrathoracic injuries. Routine angiography is indicated along with early diagnosis, establishment of priority for the injuries, and early operative intervention. The last is best accomplished through a multidisciplinary approach. The assistance of Elizabeth Albers and Linda Phelps, R.N., in data collection for this paper is gratefully acknowledged. References 1. Yee ES, Thomas AN, Goodman PC: Isolated first rib fracture: clinical significance after blunt chest trauma. Ann Thorac Surg 32:278, 1981 2. Phillips EJ, Rogers WF, Gaspar MR: First rib fractures: incidence of vascular injury and indications for angiography. Surgery 89:42, 1981 3. Schmidt G: Rib cage injuries indicating the direction and strength of impact. Forensic Sci Int 13:103, 1979 4. Fordham SD: The significance of first rib fractures. Med Times 105:18, 1977 5. Richardson JD, McElvein RB, Trinkle JK: First rib fracture: a hallmark of severe trauma. Ann Surg 181:251, 1975 6. Lorentzen JE, Movin M: Fracture of the first rib. Acta Orthop Scand 47:632, 1976 7. Galbraith NF, Urschel HC, Wood RE, et al: Fracture of first rib associated with laceration of subclavian artery: report of a case and review of the literature. J Thorac Cardiovasc Surg 65:649, 1973 8. Pierce GE, Maxwell JA, Boggan MD: Special hazards of first rib fractures. J Trauma 15:264, 1975 9. Alderson BR: Further observations on fracture of the first rib. Br J Radio1 20:345, 1947 10. Holmes TW, Netterville RE: Complications of first rib fracture including one case each of tracheoesophageal fistula and aortic arch aneurysm. J Thorac Surg 32:74, 1956