Rib Fracture Clinical Presentation

Updated: Jun 13, 2017
  • Author: Sarah L Melendez, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

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. [24]

Consider nonaccidental trauma in pediatric cases, and take an appropriate history for that diagnosis.

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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 is 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. With flail chest, the detached segment of the chest wall is pulled into the chest cavity during inspiration and pushed outward during expiration. This abnormal motion increases the work of breathing and compromises respiratory function, and may necessitate intubation and ventilatory support.

Specific signs of ventilatory insufficiency include cyanosis, tachypnea, retractions, and use of accessory muscles for ventilation. Less specific signs include anxiety and agitation. Bruising near the fracture site is uncommon in pediatric rib fractures, seen in 9.1% in one study. [9]

If fracture of the lower ribs is suspected, assess the patient for abdominal tenderness and costal margin tenderness, which could raise suspicion for injury to intra-abdominal organs. [25, 26]

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Causes

Causes include the following:

  • Blunt trauma, including motor vehicle crashes (most common mechanism [8] ) assault, and falls, especially down staircases [11, 27]

  • Motorcycle drivers are at greater risk for rib fractures compared with motorcycle passengers (57.1% vs 23.8%, p=0.05). [28]

  • Coughing spells

  • Nonaccidental trauma in pediatric cases [9]

  • Repetitive minor trauma [29]

  • Stress fractures to the first rib in throwing athletes [29]

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