AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Simple rib fractures are the most common injury sustained following blunt chest trauma, accounting for more than half of thoracic injuries from nonpenetrating trauma. Approximately 10% of all patients admitted after blunt chest trauma have one or more rib fractures. These fractures are rarely life-threatening in themselves but can be an external marker of more severe visceral injury inside the abdomen and the chest.

The most common mechanism of injury for rib fractures in elderly persons is a fall from height or from standing. In adults, motor vehicle accident is the most common mechanism. Youths sustain rib fractures most often secondary to recreational and athletic activities.

Pathophysiology

The chest wall protects underlying sensitive structures by surrounding internal organs with hard osseous structures including the ribs, clavicles, sternum, and scapulae. An intact chest wall is necessary for normal respiration.

Rib fractures may compromise ventilation by a variety of mechanisms. Pain from rib fractures can cause respiratory splinting, resulting in atelectasis and pneumonia. Multiple contiguous rib fractures (ie, flail chest) interfere with normal costovertebral and diaphragmatic muscle excursion, potentially causing ventilatory insufficiency. Fragments of fractured ribs can also act as penetrating objects leading to the formation of a hemothorax or a pneumothorax. Ribs commonly fracture at the point of impact or at the posterior angle (structurally their weakest area). Ribs four through nine (4-9) are the most commonly injured.

Frequency

United States

The incidence of rib fractures is dramatically underreported.

International

The prevalence of rib fractures is linked to the prevalence of the underlying cause of the trauma. Rib fractures are more common in countries with higher incidence of MVAs.

Mortality/Morbidity

Rib fractures are not usually dangerous in and of themselves. Morbidity correlates with the degree of injury to underlying structures.

• In one study of patients with rib fractures, the mortality rate reached 12%; of these, 94% had associated injuries and 32% had a hemothorax or a pneumothorax.¹ More than half of all patients required either operative or ICU management. Average blood loss per fractured rib is reportedly 100-150 mL.
• Position of the fractured rib in the thorax helps identify potential injury to specific underlying organs. Fracture of the lower ribs usually is associated with injury to abdominal organs rather than to lung parenchyma. Fracture of the left lower ribs is associated with splenic injuries, and fracture of the right lower ribs is associated with liver injuries. Fracture of the floating ribs (ribs 11, 12) is often associated with renal injuries.
• First rib fractures were once thought to be a harbinger of severe trauma, since the first rib is very well protected by the shoulder, lower neck musculature, and clavicle and was thought to require a much higher impact force to fracture than other ribs. These data are now in question, but until further studies are done, fractures of the first rib should raise suspicion of significant chest trauma. Mortality rates as high as 36% have been previously reported with first rib fractures, which are associated with injury to the lung, ascending aorta, subclavian artery, and brachial plexus.

Race

No data support any race predilection except for general trends for sustaining other types of trauma.

Sex

No data support any sex predilection except for general trends for sustaining other types of blunt trauma.

Age

Because children have more elastic ribs, they are less likely than adults to sustain fractures following blunt chest trauma. Elderly individuals are more likely to have associated injuries and complications.

• Children present more frequently with trauma to the underlying chest and abdominal organs without the associated rib fractures commonly seen in adults. Classically, this made rib fractures in children an ominous sign of potential high-force injury.
• Consider child abuse in children who lack a significant mechanism for multiple rib fractures or have fractures in different stages of healing. Recent data have shown that children younger than 2 years with rib fractures have a prevalence of child abuse as high as 83%.
• Older persons are more prone to rib fractures than younger adults and, therefore, the pulmonary sequelae such as atelectasis, pneumonia, and respiratory arrest. The presence of cardiopulmonary disease also significantly increases morbidity and mortality rates in patients older than 65 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

History

• Description of the prehospital scene by paramedics can provide important clues to the possibility of rib fractures.
• After motor vehicle collisions, deformation of the steering wheel and activation of seat belts and airbags have been associated with rib injuries.
• Patients with rib fracture frequently complain of pain on inspiration and dyspnea.
• Rib fractures have been reported after coughing spells without other significant trauma.
• Athletes with high force, recurrent movements of the arms (eg, discus throwers) have had stress fractures of the upper and middle ribs.

Physical

• Tenderness on palpation, crepitus, and chest wall deformity are common findings of rib fracture.
• Paradoxical chest wall excursion with inspiration is seen with flail chest. A flail chest occurs when a large segment of ribs are not attached to the spine. These ribs are broken in at least 2 places on each rib. The paradoxical movement occurs because the middle section of the rib between the 2 fracture sites moves in response to intrathoracic pressure changes not intercostal muscle contractions.
• Specific signs of ventilatory insufficiency include cyanosis, tachypnea, retractions, and use of accessory muscles for ventilation.
• Less specific signs include anxiety and agitation.

Causes

• Motor vehicle crashes (most common mechanism)
• Blunt trauma
• Falls
• Assaults
• Coughing spells

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Lab Studies

• Laboratory studies are generally not useful. Tests of the pulmonary function (arterial blood gas measurements) are used to determine if the lungs have been contused but do not actually test for rib fractures.

Imaging Studies

• Chest radiographs
• • Anteroposterior (AP) and lateral chest films are used routinely to assist in the diagnosis of rib fractures, yet sensitivity as low as 50% has been reported. Delayed or follow-up radiographs can be very helpful.
  • Chest radiographs are much more useful in the diagnosis of underlying injuries, including hemothorax, pneumothorax, lung contusion, atelectasis, pneumonia, and vascular injuries.
• Rib radiographs
• • Obtaining a rib radiograph series remains controversial, as the additional information rarely changes the clinical picture or alters treatment. This rib detail radiographs can be helpful in evaluation of the 1st and 2nd ribs and the 7th through 12th ribs. Formal plain radiographs can also be useful to document abuse for legal purposes.
  • Diagnostic sensitivity is higher in rib radiographs than in chest radiographs; however, with a high clinical suspicion, treat for fracture regardless of the radiographic result.
• Chest CT scan
• • A chest CT scan is more sensitive than plain radiographs for detecting rib fractures. The modality can also provide information regarding the number of ribs involved.
  • If complications from rib fractures is suspected clinically or diagnosed by plain radiographs, a chest CT scan may be helpful to document specific injuries, characterize extent of injury, and plan for definitive management.
  • An associated CT scan of the abdomen with intravenous contrast should be considered in cases involving lower rib fractures with suspected or known injury to the liver and/or the spleen.
• Angiography
• • Since first and second rib fractures are often associated with vascular injury, ED physicians should consider angiography for such patients, especially if symptoms and signs of neurovascular compromise are present.
  • This is particularly important with posteriorly displaced fractures of the first 2 ribs, which have a much higher degree of association with abnormal angiographic findings than other rib fractures.
  • While first rib fractures previously were considered a strong risk factor for aortic injury, most authorities now believe that aortography and/or CT scan are not indicated without other evidence of injury, such as abnormal mediastinum.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Prehospital Care

• Focus care on airway maintenance and supplemental oxygen.

Emergency Department Care

• Goal of initial ED care is stabilization of the trauma patient and multisystem trauma evaluation.
• Primary focus of treatment for rib fractures is pain relief and adequate clearing of pulmonary secretions.
• Isolated rib fractures, without associated injuries, may be managed on an outpatient basis with oral analgesics.
• Other options include parenterally administered narcotics titrated to prevent respiratory depression.
• Patient-controlled anesthesia allows adequate pain relief with minimal inhibition of respiratory drive.
• Intercostal nerve blocks provide pain relief without affecting respiratory function, although risks of this procedure include intravascular injection and pneumothorax.
• For hospitalized patients, consider epidural and intrapleural catheter placement for delivery of anesthetics. Patient-controlled analgesia pumps have also shown to be useful in these patients.
• While rib belts or binders do control pain, they have been linked to hypoventilation, atelectasis, and pneumonia. As a result, their use is no longer recommended.
• For patients with a significant mechanism of trauma, a CT of the chest and abdomen can be useful in scanning for significant related injury.

Consultations

• Because of the close association of rib fractures with injury to underlying structures, the ED physician may need to consult the trauma service.
• Pain management specialists can be helpful for admitted patients.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Pain control remains the mainstay of treatment, usually with nonsteroidal anti-inflammatory or oral narcotic agents.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

These agents are used most commonly for the relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually the first-line drug of choice for initial therapy. Other options include fenoprofen, flurbiprofen, ketoprofen, indomethacin, and piroxicam.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Further Inpatient Care

• Patients with isolated rib fractures who are unable to cough and clear secretions adequately should be considered for admission for 24-hour observation.
• A lower threshold for admission of older persons with isolated rib fractures is warranted because of their higher incidence of hypoventilation, hypercapnia, atelectasis, and pneumonia.
• Admission may also allow for observation for occult intra-abdominal organ injury.
• Patients being admitted should have good pain control and if possible given an incentive spirometer to prevent pulmonary splinting and its resultant complications.

Further Outpatient Care

• Patients with minor rib injuries able to cough and clear secretions may be discharged with adequate analgesic medications.
• Consider an incentive spirometer, especially with multiple fractures, as it may help avoid complications and remind the patient to avoid splinting and to take deep breaths.

Transfer

• Currently, no published guidelines exist for transfer of patients with simple rib fracture to a regional trauma center.
• Some studies have concluded that the presence of 3 or more rib fractures identifies a subgroup of adult patients who may require tertiary care.

Deterrence/Prevention

• No clear data indicate how to decrease the number of rib fractures associated with car crashes as the restraint systems all exert force on the rib cage.

Complications

• Hypoventilation
• Hypercapnia
• Hypoxia
• Atelectasis
• Pneumonia
• Damage to underlying visceral organs

Prognosis

• Isolated rib fractures in younger patients have a good prognosis.
• Older patients have a higher incidence of significant pulmonary complications.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Media file 1:  Aortic injury is closely associated with a widening of greater than 8 cm measured at the widest points of the mediastinum on an upright anteroposterior chest radiograph.
	View Full Size Image
Media type:  Radiograph

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

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16. Stawicki SP, Grossman MD, Hoey BA. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc. May 2004;52(5):805-8. [Medline].
17. Trinkle JK, Richardson JD, Franz JL. Management of flail chest without mechanical ventilation. Ann Thorac Surg. Apr 1975;19(4):355-63. [Medline].
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19. Woodring JH, Fried AM, Hatfield DR. Fractures of first and second ribs: predictive value for arterial and bronchial injury. AJR Am J Roentgenol. Feb 1982;138(2):211-5. [Medline].

Article Last Updated: Feb 14, 2008