Introduction
Frontal image of the rib cage. Ribs 1-12 demonstrate the variable shape of the upper 9 ribs. The 12th rib does not articulate anteriorly. The sternum consists of the manubrium (M), the body (S), and the xiphoid (X). The ribs articulate with the sternum via the costochondral (CC) junction. C = clavicle.
Posterior image of the thorax. The ribs are numbered 1-12. The clavicle (C) and scapula (S) are often involved in injuries that include rib fractures.
Background
Thoracic trauma may present as an isolated rib fracture, a chest contusion, or a laceration; however, significant thoracic trauma often involves multiple organ systems and several anatomic regions. The chest trauma that results from a motor vehicle accident may result in injury to the sternum, the ribs, and the heart, aorta, and lungs.
Radiographs can depict bony trauma, and rib fractures are among the most commonly identified injuries to the chest. Injuries to the chest wall may involve the pleural space, lungs, extrapleural space, mediastinum, heart and great vessels, spine, and shoulders.
The location of specific rib fractures is an important indicator of related injury. Rib fractures can be studied as 3 distinct patterns according to their location (see Images 7-8): (1) fractures of the first rib and those of the second to fourth ribs, (2) fractures of the fifth to ninth ribs, and (3) fractures of the 10th to 12th ribs. These 3 distinct patterns of rib fractures represent unique pathophysiology and associated morbidity.
For excellent patient education resources, visit eMedicine's Fractures and Broken Bones Center. Also, see eMedicine's patient education articles Collapsed Lung (Pneumothorax), Broken Shoulder Blade, Broken Collarbone, Wilderness: Chest Injuries.
Related eMedicine topics:
Blunt Chest Trauma Flail Chest
Fractures, Rib
Fractures, Sternal
Thorax, Trauma
Pathophysiology
With normal respiration, the sternal ends of the ribs rise and fall, whereas the vertebral ends remain fixed. The ribs are elevated with the synchronous contraction of the intercostal muscles. This muscular contraction elevates only the sternal ends, moving the sternal ends of the ribs up and away from the vertebral column to increase the anteroposterior (AP) distance. Changes in thoracic pressure generate pressure gradients that are necessary for air movement into and out of the lungs. The process of breathing requires the use of both the bony structures and accessory muscles; fractured ribs reduce this dual action and, therefore, reduce the volume of air that flows into and out of the lungs.
The most common cause of rib fractures is blunt trauma to the chest wall, which results in a sudden deformity of the semi-rigid chest wall.1,2,3,4 Injuries due to motor vehicle accidents and severe crush injuries often result in 1 or more rib fractures. Rib fractures are also noted following cardiopulmonary resuscitation (CPR).5,6,7 CPR-related fractures are more likely to occur in older adults; however, anterolateral rib fractures have been reported in children following CPR.5
Children seem less vulnerable to rib fractures than adults are because of the elasticity of their thoracic cage. Rib fractures in children who are not involved in a motor vehicle or pedestrian accident may be associated with child abuse.8,9 Rib fractures among neonates and young children may be associated with genetic or physiologic disorders.10,11
The frequency of rib fractures increases with increased brittleness of the chest wall, which increases with age. In elderly or chronically ill patients, rib fractures may occur with severe coughing or hard straining; these injuries are stress fractures. Hyperparathyroidism and glucocortical steroid administration are associated with an increased incidence of rib fractures.12,13,14 Other less common causes of rib fractures include gunshot wounds and other penetrating wounds of the chest (see Images 33-34).
Chest radiograph in a patient who presented with a gunshot wound to the anterior chest wall. Note the pulmonary contusion (arrow). The bullet struck an anterior right rib, resulting in a rib fracture. Other injuries involved the pleura and lung on the right.
Axial computed tomography image of the chest in a patient with a gunshot wound. Note the comminuted rib fracture (black arrow). A lung contusion is present along the path of the bullet (yellow arrow). A chest tube was placed to treat the right pneumothorax.
Rib fractures can compromise ventilation by causing pain, which can prevent proper ventilation and coughing.15,16 This impairment may result in atelectasis, retained secretions, and pneumonia.17,18 Multiple rib fractures can cause flail chest, which may result in ventilatory insufficiency due to ineffective respiratory action.19,20 Broken ribs can penetrate the lungs and pleura, resulting in a hemothorax or a pneumothorax.4,21,22
In special clinical circumstances, rib fractures may occur without the effects of an acute injury. Stress fractures of the ribs have been associated with repetitive mechanical movement of the upper extremities, as seen in the sports of rowing and golf.23,24 The occurrence of stress fractures among rowers has been reported to range from 6.1% to as high as 12%.23 Spontaneous pathologic fractures may occur in metastatic disease and severe metabolic disease such as hyperparathyroidism.12,14,25
Osteogenesis imperfecta results in multiple fractures in the absence of specific focal trauma. Following the occurrence of a low-trauma rib fracture, the risk of a recurrent rib fracture is significantly increased.26
Related eMedicine topics:
Atelectasis, Lobar
Pneumonia, Typical Bacterial
Hemothorax
Hyperparathyroidism, Primary
Hyperparathyroidism, Secondary
Pneumothorax
Stress Fracture
Thoracic Trauma
Frequency
United States
Rib fractures are estimated to be present in 10% of all traumatic injuries and 14% of all chest-wall injuries. The most common injury of the chest is a fracture of 1 or more ribs, including a separation of the costochondral junction. In adults, rib fractures are the most common blunt chest injury, in which the middle and lower ribs, the fifth to ninth ribs, are the most commonly fractured. In one study, following the occurrence of a low-trauma fracture, the reported relative risk of a second fracture in older women was 1.95 compared with a 3.7 relative risk of a second fracture in an older adult male.26
Mortality/Morbidity
- In a study by Ziegler and Agarwal, the authors reported that patients with 1 or 2 rib fractures had a 5% mortality rate, and patients with 7 or more fractures had a 29% mortality rate.22
- Lung-related morbidity rates of patients with multiple rib fractures range from 13% to 69%.
Race
No important racial differences in the occurrence of rib fractures are reported.
Sex
Except for occupational risks related to physical labor and violent sports, rib fractures occur equally in young men and women. However, more older women than older men tend to have rib fractures.26
Age
- Children seem to be less vulnerable to rib fractures than adults are because of the elasticity of their thoracic cage. Rib fractures in children who are not involved in a motor vehicle or pedestrian accident may be associated with child abuse and are characteristically seen in the posterior portions of the ribs, unlike rib fractures of the adult.8,9 Following CPR, rib fractures may occur in children; however, the fractures are more difficult to identify.10,11
- Serious accident and injury tend to occur more commonly among young men than in other patient populations. Sports-related trauma that results in rib fractures is more common among young men than young women. In addition, the failure to wear safety shoulder and seat belts tends to be associated with young automobile drivers.
- The frequency of fractures increases with increased brittleness of the chest wall, which increases with age. In elderly or chronically ill patients, rib fractures may occur with severe coughing or hard straining. Nontraumatic rib fractures are more common among older women who also have osteoporosis. Medications that are more commonly used by older patients may also contribute to the risk of rib fractures.
Related eMedicine topics:
Child Abuse Osteoporosis Osteoporosis (Primary)
Osteoporosis (Secondary)
Anatomy
The ribs are relatively flat elastic arches of bone (see Images 1-2) that form a large part of the thoracic skeleton. In general, 12 ribs occur in matched pairs on either side (see Images 5 and 7-8). The number of ribs may vary with the development of a cervical rib or a lumbar rib, or their number may be diminished to 11 as an anomaly and in certain conditions (eg, Down syndrome).
Image of the common middle rib. The common middle rib consists of the neck that is closest to the thoracic spine with an articular tubercle—the angle of which is a curved portion of the rib—and the distal body.
Image of central rib, viewed from the back, in which the subcostal groove is best seen. The costal artery and nerve follow the subcostal groove.
Image of a typical upper thoracic rib. Each of the 9 upper thoracic ribs has 2 posterior articulations with a thoracic vertebral body above and below (costovertebral junction [CVJ]) and an anterior articulation with the sternum (costochondral junction [CCJ]). VB = vertebral body.
Frontal image of the rib cage. Ribs 1-12 demonstrate the variable shape of the upper 9 ribs. The 12th rib does not articulate anteriorly. The sternum consists of the manubrium (M), the body (S), and the xiphoid (X). The ribs articulate with the sternum via the costochondral (CC) junction. C = clavicle.
Posterior image of the thorax. The ribs are numbered 1-12. The clavicle (C) and scapula (S) are often involved in injuries that include rib fractures.
The first 7 ribs are connected with the vertebral column behind and with the sternum in front by means of the costal cartilages. The first 7 ribs are called true, or vertebrosternal, ribs (see Images 5 and 7-8). Of the remaining 5 ribs, the first 3 have cartilages that are attached to the cartilage of the rib above; these are the vertebrochondral ribs (see Image 4). The last 2 ribs are free anteriorly. The 11th and 12th ribs are termed floating or vertebral ribs (see Images 6-7).
The ribs vary in directional orientation; the upper ribs are less oblique than the lower ribs. Between each rib is an intercostal space. The ribs increase in length from the first to the seventh; the 12th ribs are generally the shortest.
The typical rib includes a head, neck, tubercle, body, and costal cartilage. The shaft (body) makes a posterior curve (angle) and extends anteriorly toward the sternal end for the costal cartilage. The costal groove runs along the inferior surface of the rib. The heads of ribs 1-9 articulate with 2 thoracic vertebrae. Each of the upper 9 ribs has 2 articular facets by which the articulation occurs. The 10th-12th ribs have a single facet with a single vertebral articulation. The 12th rib has no anterior articulation, and the last rib may appear similar to a transverse process of the upper lumbar spine; however, this rib is identified by its articulation with the 12th thoracic vertebral body (see Image 1).
Image of the common middle rib. The common middle rib consists of the neck that is closest to the thoracic spine with an articular tubercle—the angle of which is a curved portion of the rib—and the distal body.
The first, second, and 10th-12th ribs present variations that require special consideration. The first rib is the most curved and the shortest of the ribs (see Image 3)—although the 12th rib may be shorter than the first rib—and the anterior portion of the first rib is larger and thicker than the other ribs. The general shape of the first rib is broad and flat, with a small and rounded head and a single articular facet (for articulation with the body of the first thoracic vertebra), but without an angle. The upper surface of the rib's body is marked by the scalene tubercle and the grooves that transmit the subclavian vein, the posterior subclavian artery, and the lowest trunk of the brachial plexus. Behind the posterior groove is an attachment for the scalenus medius muscle. The undersurface of the first rib is smooth without a costal groove.
Image of the first rib, which is one of the upper, specialized ribs. Important features of the first rib include the attachments of the scalenus medius and serratus anterior muscles. Grooves for the subclavian artery and vein represent important potential areas of serious injury in fractures of the first rib.
The second rib is longer than the first and follows a similar curvature. A minor angle is situated close to the tubercle, and the external surface of the second rib is convex. The body is not twisted, nor is it flattened horizontally like that of the first rib. The superior surface of the second rib provides the origin of the lower part of the first digitation and the whole of the second digitation of the serratus anterior muscle. A short costal groove is present.
The 11th and 12th ribs each have a single articular facet on the head. They have no necks or tubercles. The distal ends of the lower 2 ribs are pointed at their anterior ends. The 11th rib has a slight angle and a shallow costal groove. The 12th rib may be shorter than the first rib.
Each rib (except for the last 2) has 4 ossification centers: a primary center for the body and 3 epiphyseal centers. However, the 11th and 12th ribs only have 2 ossification centers. Toward the end of the second month of fetal life, the sixth and seventh ribs are the first to develop, and ossification first begins near the rib angle. The epiphyses for the head and tubercle make their appearance between the 16th and 20th years of life, and they are united to the body at about the 25th year.
The important anatomic relationship of the ribs to the surrounding structures includes the thoracic nerves and the intercostal arteries and veins. The anterior divisions of the thoracic nerves are situated between the ribs — except for the 12th thoracic nerve, which passes below the 12th rib. Each nerve is connected with the adjoining ganglion of the sympathetic trunk by a gray and a white ramus communicans. The intercostal nerves are distributed to the thorax and abdomen. No plexus formation is present. The percutaneous distribution follows dermatome patterns.
The sternum consists of the manubrium, body, and xiphoid process (see Image 7). The manubrium is attached to the sternum by a cartilaginous union until advanced age and articulates with the clavicle on each side. The angle made by the union of the sternum and the manubrium is the sternal angle; this is the level where the cartilage of the second rib articulates with the manubrium. The cartilage of the seventh rib joins the sternum at the junction of the body and the xiphoid. The body develops from 4 separate ossification centers.
Frontal image of the rib cage. Ribs 1-12 demonstrate the variable shape of the upper 9 ribs. The 12th rib does not articulate anteriorly. The sternum consists of the manubrium (M), the body (S), and the xiphoid (X). The ribs articulate with the sternum via the costochondral (CC) junction. C = clavicle.
Presentation
Fractures of the first rib
Fractures of the first rib are extremely rare and more commonly associated with either multiple rib fractures or life-threatening injuries. Historically, fractures of ribs 1-3 have been associated with injuries of the brachial plexus and major vessels. Angiography, or arteriography, should be considered in stable patients with first rib fractures if there are absent or decreased upper extremity pulses, hemorrhage, and/or brachial plexus injury. Additional criteria for angiography include displacement of bone fragments and multiple thoracic injuries.
Fractures of the first rib imply a violent force; this pattern of fractures may signify injury to the adjacent subclavian vein and brachial plexus. Isolated first rib fractures are seen in association with cranial and maxillofacial injuries and are probably secondary to avulsion of the first rib by its muscular attachment rather than direct trauma to the rib, which is relatively protected. Surfer's rib is an isolated first-rib fracture and occurs in surfers who perform the lay-back maneuver. Fractures of the first rib have also been associated with thoracic outlet syndrome.27
Fractures of the fifth to ninth ribs
Fractures of the fifth to ninth ribs can be single or multiple. Multiple fractures can present as flail chest, which is present when paradoxical respiratory movement occurs in a segment of the chest wall. This type of fracture requires at least 2 segmental fractures in each of 3 adjacent ribs, the costal cartilages, or the sternum (see Image 14). Posterior flail segments are easier to manage clinically because of the presence of strong muscular and scapular support and because of a patient's natural tendency to lie with his or her back against the mattress.
Image depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result.
An inward displacement of the fracture fragments at the time of the injury may lacerate the lung parenchyma and produce a pneumothorax, with bleeding into the pleural cavity. The occurrence of a pneumothorax and hemothorax may be delayed for hours to days after the injury.4 Hemothorax of a significant degree that occurs with rib fractures is usually a result of laceration of an intercostal artery rather than bleeding from the lung. This bleeding can be life threatening. A spontaneous fracture of a midthoracic rib should alert the clinician for an underlying metastasis or hyperparathyroidism.
Fractures of the tenth to the twelfth ribs
Hemorrhage around and within the adrenal glands represents a risk that is associated with fractures of the lower ribs.12 Fractures of the lower ribs are also commonly associated with visceral injury to the kidneys and the spleen.28,29 Associated lumbar and thoracic vertebral spinal injuries occur because of the proximity of the transverse spinous processes to the lower thoracic and upper lumbar spine.30
Pneumothorax
A pneumothorax is a common sequela of blunt trauma. Fracture fragments that lacerate the lung parenchyma can cause bleeding into the pleural cavity and result in a pneumothorax (see Image 13).
Semi-erect anteroposterior (AP) chest radiograph in a patient with a nondisplaced posterior fracture of the left 10th rib. A small, apical pneumothorax (black arrow) is present on the left, and there is volume loss in the left lower lobe (white arrow).
The incidence of a pneumothorax is not as high with 1 rib fracture, but the risk increases as the number of broken ribs increases (see Images 17-19). In a retrospective study, Miller and Ghanekar found that significant solid organ injury was 3.5 times more common in patients who suffered blunt trauma and who had a pneumothorax than in those patients without a pneumothorax.29 In addition, the authors found that the association of rib fractures with a pneumothorax resulted in a larger number of visceral lacerations by fragments of bone. Miller and Ghanekar recommended that because a large proportion of pneumothoraces found with computed tomography (CT) scanning are not visualized on a portable chest radiograph, clinicians should look for indirect signs of pneumothorax, such as the presence of rib fractures and subcutaneous air.29
Hemothorax
The incidence of hemopneumothoraces in patients with rib fractures is 30%. A hemothorax is usually the result of a lacerated intercostal artery; however, bleeding from broken ribs usually stops before a sufficient volume is lost and before emergency thoracotomy is required. Note: About 400-500 mL of blood may be hidden by the diaphragm on an upright chest radiograph, and 1 L or more of blood may be overlooked on a supine image.
The bleeding may be delayed or may recur after several days. In a review by Simon et al, 12 cases of delayed hemothorax were identified, and 92% of those occurred in patients with multiple or displaced rib fractures.4 The presentation of hemothorax in these cases occurred between 18 hours and 6 days after the injury. Eleven of the affected patients complained of new-onset pleuritic chest pain and dyspnea; the symptoms were similar to those of a pulmonary embolism.
Pulmonary contusion
Rib fractures are associated with pulmonary contusions in 20-40% of cases. The injury is characterized by capillary disruption that results in the presence of intra-alveolar and interstitial hemorrhage, edema, protein, and fluid obstruction of the small airways with leukocyte infiltration. Serial chest radiographs obtained beginning right after the injury show a fluffy infiltrate that progresses in extent and opacity over 24-48 hours.
Pulmonary contusions are often a part of a major chest injury that includes 1 or more fractures of the thoracic cage, a pneumothorax, and a hemothorax. The contusions may occur due to the transmission of force through the chest wall with minimal fractures of the ribs or sternum; this mechanism is especially seen in the young. In middle-aged or elderly patients, pulmonary contusions are usually accompanied by multiple rib fractures.
Aortic injuries
The idea that thoracic cage injuries are predictive of acute traumatic aortic tears is controversial. A study by Lee et al concluded that no clinically relevant correlation exists between these injuries and acute traumatic aortic tears.31 The authors also concluded that upper rib fractures are not an indication for aortic angiography.
An aortic injury that is related to blunt trauma is usually due to the transmission of a shearing force at the ligamentum arteriosum.32 However, there have been case reports that describe fractured ribs puncturing the aorta.33,34 One such case involved a posterior fracture of the left sixth rib that lacerated the aorta 3 days after the trauma occurred.35
Cardiac perforation may result in both pericardial and periaortic hemorrhage.36 Direct penetration of the heart due to a rib fracture has been reported.2
Flail chest
A flail chest is present when a paradoxical respiratory movement occurs in a segment of the chest wall, the result of at least 2 segmental fractures in each of 3 adjacent ribs or costal cartilages (see Images 14-16). The incidence of flail segments is 10-15% in patients with major chest trauma. More severe injuries, such as closed head injury and intrathoracic injury, are common in the presence of a flail chest.
Image depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result.
Anteroposterior (AP) supine chest radiograph that was obtained upon a patient's arrival in the emergency department after a serious automobile accident. Although rib fractures are identified along the left lateral chest wall (black arrows), the transportation bed created superimposed metal artifacts (blue arrows) that obscure visualization of possible other rib fractures along the chest wall.
Supine anteroposterior (AP) chest radiograph that was obtained after the removal of metal artifacts along the left chest wall (same patient as in Image 15). Multiple posterolateral rib fractures are noted on the left (arrows; Note: White and black arrows were used for easy visualization due to the dark and light areas of the lungs).
Multiple fractures of the upper chest with a dislocation of the clavicle are also associated with extrathoracic lung herniation.21 However, in most cases, no chest-wall defects are present. Flail chest may lead to respiratory failure secondary to the pulmonary contusion and pain during inspiration.
Treatment consists of chest-wall stabilization37 ; reduction of the respiratory dead space; management of the pulmonary contusion; and, most of all, pain control. Epidural analgesics are the pain-management agents of choice.16 Intercostal nerve blocks may also be used. The extent of a pulmonary contusion and whether pain management allows for proper pulmonary toilet determine the need for mechanical ventilation. Surgical stabilization is rarely indicated; however, Lardinois et al found that early restoration of the integrity of the chest wall by using reconstruction plates in anterolateral flail chests may be cost effective.19
Abdominal solid-organ injury
Low rib fractures, right-sided rib fractures, female sex, young age, and an elevated injury severity score increase the probability of a liver injury. Low rib fractures, rib fractures on only the left side, young age, and an elevated injury severity score increase the probability of a splenic injury. In a study by Shweiki et al, the incidence of liver injuries was 10.7% in their population of patients with rib fractures, and 11.3% had splenic injuries.28
Preferred Examination
The patient's medical history and physical examination findings should suggest the diagnosis of a rib fracture. The primary signs and symptoms are a pleuritic-type chest pain and tenderness over fracture site. When 2 or more adjacent ribs are fractured, especially if they are broken in more than 1 place, examination alone should be enough to enable a presumptive diagnosis of a rib fracture.
The standard chest radiograph is useful in the recognition of preexistent or coexistent disease. The routine radiographic examination of the sternum includes the frontal prone and rotated views in an off-lateral projection. However, approximately 50% of all rib fractures go undetected during screening chest radiography (see Images 9-10).38,39 The examination of suspected rib fractures should include the acquisition of erect posteroanterior (PA) and oblique radiographs of the chest (see Image 11). An erect frontal examination of the chest is useful in the detection of a pneumothorax, pulmonary contusion, or pleural effusion.
Anteroposterior (AP) chest radiograph in a patient who presented with severe left chest wall pain after a minor fall. No rib injury is apparent.
Anteroposterior (AP) radiograph of an elderly female patient with severe left chest wall pain after a minor fall. This image demonstrates a left lateral rib fracture (arrow) that is not seen on the standard AP chest radiograph.
This detailed oblique radiograph shows 2 rib fractures (arrows) that are not depicted on anteroposterior (AP) chest radiographs (same patient as in Image above).
Each oblique projection is intended to depict the entire rib. The PA chest radiograph alone is ineffective in the identification of incomplete or minimally displaced rib fractures; the lower ribs may be obscured by the upper abdominal organs. If a lower rib fracture is suspected, a radiographic technique is required that centers an AP radiograph of the lower portion of the chest and upper abdomen on the upper lumbar spine film.
If the patient remains symptomatic despite a negative initial radiograph, a repeat radiograph of the ribs, acquired with a standard technique, often demonstrates the signs of early healing of a rib fracture. If the identification of occult rib fractures is clinically important, as in a case of suspected child abuse or for medicolegal reasons, radionuclear bone scanning with technetium-99m methylene diphosphonate (99m Tc MDP) is often successful. A delay of several days should be allowed after an acute trauma to increase the sensitivity of radionuclear imaging for a rib fracture.
Rib fractures may be seen by using bone window settings on a chest CT scan; however, an occult rib fracture is not an indication for thoracic CT scanning.40,41
Limitations of Techniques
- In obese patients and in older patients with osteoporosis, the evaluation for uncomplicated rib fractures is often difficult to perform with standard radiographs.
- Greenstick fractures may not be seen on initial chest radiographs because of the nondistracted nature of the injury.
- Cartilage fractures and costochondral separations are not seen on routine chest radiographs; several weeks may pass before such injuries are visible on chest radiographs. However, the fractures may be indirectly seen following the development of periosteal reaction around the fractures.
Differential Diagnoses
[Lung, Trauma]
Aorta, Trauma
Child Abuse
Hyperparathyroidism, Primary
Tracheobronchial Tear
Vascular and Solid Organ Trauma - Interventional
Radiology
Other Problems to Be Considered
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Further Reading
Keywords
rib fractures, cracked ribs, broken ribs, chest wall trauma, chest-wall trauma, crushed chest injury, chest trauma, thoracic trauma, blunt chest trauma, flail chest, pneumothorax, hemothorax, hemopneumothorax
