ECMO-/ECLS

initial presentation. Although rib fractures alone are usually of minimal clinical
significance, 70% of patients with multiple rib fractures have associated injuries
in other organ systems. Consequently, the presence of rib fractures in blunt
trauma necessitates thorough evaluation for other concomitant injuries. CT
scan and angiography are useful adjunctive diagnostic tools to delineate other
injuries associated with broken ribs in selected cases.
In patients less than 3 years of age, child abuse should be strongly
considered in the absence of a plausible mechanism for major trauma or
underlying metabolic condition predisposing to fractures, such as rickets or
osteogenesis imperfecta. When reasonable causes are excluded, the positive
predictive value of rib fractures for child abuse in children younger than 3 years
of age is 95% to 100%. In cases suspicious for abuse as the primary etiology,
further imaging with a skeletal survey and bone scintigraphy should be pursued
and social work involvement should be initiated.
The location of rib fractures may prompt further examination for
associated organ injuries. First rib fractures indicate a high-energy impact and
may be associated with multisystem injury, including shoulder girdle injury,
clavicle fracture, pulmonary contusion, hemopneumothorax, vertebral spine
injury, or intra-abdominal trauma. However, fractures in the first and second rib
are no longer considered to be markers for major vascular injury, nor are they
indicators for further angiographic examination. Fractures of the lower ribs,
depending on laterality, are associated with hepatic or splenic injuries.