Introduction
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
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
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References
Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. Dec 1994;37(6):975-9. [Medline].
Carrier FM, Turgeon AF, Nicole PC, Trépanier CA, Fergusson DA, Thauvette D, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. Mar 2009;56(3):230-42. [Medline].
Albers JE, Rath RK, Glaser RS. Severity of intrathoracic injuries associated with first rib fractures. Ann Thorac Surg. Jun 1982;33(6):614-8. [Medline].
Baker CC, Oppenheimer L, Stephens B. Epidemiology of trauma deaths. Am J Surg. Jul 1980;140(1):144-50. [Medline].
Coris EE, Higgins HW. First rib stress fractures in throwing athletes. Am J Sports Med. Sep 2005;33(9):1400-4. [Medline].
Flagel BT, Luchette FA, Reed RL. Half-a-dozen ribs: the breakpoint for mortality. Surgery. Oct 2005;138(4):717-23; discussion 723-5. [Medline].
Fulda GJ, Giberson F, Fagraeus L. A prospective randomized trial of nebulized morphine compared with patient-controlled analgesia morphine in the management of acute thoracic pain. J Trauma. Aug 2005;59(2):383-8; discussion 389-90. [Medline].
Garcia VF, Gotschall CS, Eichelberger MR. Rib fractures in children: a marker of severe trauma. J Trauma. Jun 1990;30(6):695-700. [Medline].
Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures?. Injury. Jun 2004;35(6):562-6. [Medline].
Lee RB, Bass SM, Morris JA Jr. Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study. J Trauma. Jun 1990;30(6):689-94. [Medline].
LoCicero J, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am. Feb 1989;69(1):15-9. [Medline].
Love JC, Symes SA. Understanding rib fracture patterns: incomplete and buckle fractures. J Forensic Sci. Nov 2004;49(6):1153-8. [Medline].
Newman RJ, Jones IS. A prospective study of 413 consecutive car occupants with chest injuries. J Trauma. Feb 1984;24(2):129-35. [Medline].
Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg. Oct 1982;196(4):481-7. [Medline].
Richardson JD, McElvein RB, Trinkle JK. First rib fracture: a hallmark of severe trauma. Ann Surg. Mar 1975;181(3):251-4. [Medline].
Ruddy RM. Trauma and the paediatric lung. Paediatr Respir Rev. Mar 2005;6(1):61-7. [Medline].
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].
Trinkle JK, Richardson JD, Franz JL. Management of flail chest without mechanical ventilation. Ann Thorac Surg. Apr 1975;19(4):355-63. [Medline].
Wilson JM, Thomas AN, Goodman PC. Severe chest trauma. Morbidity implication. Arch Surg. Jul 1978;113(7):846-9. [Medline].
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].
Further Reading
Keywords
rib fractures, broken ribs, blunt thoracic injury, blunt chest trauma, chest trauma, flail chest, rib injury, abdominal trauma, thoracic injuries, blunt trauma
