Rib Fracture 

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

Overview

Practice Essentials

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.[1] 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.

First-rib fractures are considered indicators for increased morbidity and mortality in major trauma.[2, 3, 4] According to one study based on information in the UK Trauma Audit and Research Network, first-rib fracture was a significant predictor of injury severity (Injury Severity Score >15) and polytrauma.[2]

In a study by Murphy et al, patients with a fracture of the first or second rib had higher mortality than patients with other rib fractures (7.4% vs 4.1%), as well as increased great vessel injury (2.8% vs 0.6%).[3]

The image below depicts aortic injury, closely associated with a widening of greater than 8 cm measured at the widest points of the mediastinum.

Aortic injury is closely associated with a widenin 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.

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 (MVA) is the most common mechanism. Youths sustain rib fractures most often secondary to recreational and athletic activities, as well as by nonaccidental trauma. Rib fractures may also be pathologic. Cancers that metastasize to bone (eg, prostate, breast, renal) frequently become apparent in a rib. Ribs are relatively thin compared with major long bones and are more likely to fracture when invaded by a metastatic lesion. In a study of Japanese patients with rheumatoid arthritis who were followed over a mean duration of 5.2 years, 13.5% reported incident fractures, with rib fractures being the most common fractures in men and vertebral fractures being the most common fractures in women, followed by rib fractures.[5]

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. Obtaining a rib radiograph series remains controversial, as the additional information rarely changes the clinical picture or alters treatment. Rib detail radiographs can be helpful in evaluation of the 1st and 2nd ribs and the 7th through 12th ribs. Chest CT scan (see the image below) is more sensitive than plain radiographs for detecting rib fractures.[35] Because 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.[4]

Pain control is fundamental to the management of rib fractures to decrease chest wall splinting and alveolar collapse in order to clear pulmonary secretions. Patients with minor rib injuries able to cough and clear secretions may be discharged with adequate analgesic medications. Intercostal nerve blocks provide pain relief without affecting respiratory function, although risks of this procedure include intravascular injection and pneumothorax. A small percentage of rib fractures do not heal even though a fibrous capsule may envelope the fracture. A nonunion may present months to years after injury and can cause discomfort with respiration due to movement of the fracture site.

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.

The thinnest and weakest portion of the first rib is at the groove for the subclavian artery.[6] The mechanism of first-rib injury in motor vehicle accidents seems to be a violent contraction of the scalene muscles brought on by the sudden forward movement of the head and neck.[7]

A single blow may cause rib fractures in multiple places. Traumatic fractures most often occur at the site of impact or the posterolateral bend, where the rib is weakest.

Due to the greater pliability of children's ribs, greater force is required to produce a fracture.

Epidemiology

The incidence of rib fractures is dramatically underreported. More than 2 million blunt mechanisms of injury occur annually just as motor vehicle collisions, with reported incidence of chest injury between 67 and 70% of those.[8]  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.

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. Bruising near the fracture site is uncommon with pediatric rib fractures, seen in only 9.1% of pediatric rib fractures in one study.[9] Consider child abuse in children who lack a significant mechanism for multiple rib fractures or have fractures in different stages of healing. Children younger than 2 years with rib fractures have a prevalence of child abuse as high as 83%.

According to a report by the American College of Radiology, rib fractures may be the only abnormality in up to 30% of abused children.[10]

Older persons are more prone to rib fractures than younger adults[11] 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. The clinical benefits of a rib scoring system has been tested at one site for hospitalized older adults.[12]

Mortality/Morbidity

Rib fractures are not usually dangerous in and of themselves. Patients may develop pneumonia from splinting. 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.[13] More than half of all patients required either operative or ICU management. Average blood loss per fractured rib is reportedly 100-150 mL.

In one retrospective study of 99 elderly patients, 16% of patients (95% confidence interval [CI], 9.5-24.9%) developed adverse events, including 2 deaths.[14] Adverse events were defined as acute respiratory distress syndrome (ARDS), pneumonia, unanticipated intubation, transfer to ICU for hypoxemia, or death. Risk factors associated with these adverse events were age ≥85 years, initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 or more unilateral rib fractures, or pulmonary contusion. These risk factors predicted adverse events with 100% sensitivity (95% CI, 79.4-100%), and 38.6% specificity (95% CI, 28.1-49.9%), and they may identify variables that might aid in identifying patients at high risk for serious adverse events if validated in a larger prospective study.

A study of rib fractures in patients younger than 21 years found that mortality increased nearly linearly for increasing numbers of pediatric rib fractures. Odds of mortality increased with each additional rib fractured in all pediatric age groups. Mortality doubled from 1.79% without rib fracture to 5.81% for 1 rib fracture and then nearly linearly increased to 8.23% for 7 fractures. Ventilator days also increased with increasing number of rib fractures.[15]

Rib fractures are the most common injury in elderly blunt chest trauma patients, and each additional rib fracture increases the odds of dying by 19% and of developing pneumonia by 27%.[16, 17]

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 have often been described as having a high association with serious or lethal spinal or vascular injuries.[18, 2] They are rarest of all rib fractures[7] and were once thought to be a harbinger of severe trauma,[19] since the first rib is very well protected by the shoulder, lower neck musculature, and clavicle.

First rib fractures were thought to require a much higher impact force to fracture than other ribs, but that theory is now in question. Until further studies are done, fractures of the first rib should raise suspicion of significant chest trauma. The presence of a first rib injury requires a multidisciplinary approach. CT of the spine and chest allows for an early diagnosis. Appropriate treatment and observation in the intensive care unit may prevent further morbidity and/or mortality.[18]

While first rib fractures have a high association with spinal fractures and are associated with multisystem injuries, the occurrence of first rib fractures is not always associated with increased morbidity and mortality.[18] Mortality rates as high as 36% have been previously reported with fractures of the first rib, which are associated with injury to the lung, ascending aorta, subclavian artery, and brachial plexus.[4] Other complications associated with first rib fractures include delayed subclavian vessel thrombosis, aortic aneurysm, tracheobronchial fistula, thoracic outlet syndrome,[20] , and Horner syndrome.[21]

The association of lower rib fractures with pelvic fractures has been associated with a higher incidence of solid organ injury.[22]

Prognosis

Isolated rib fractures in younger patients have a good prognosis. Older patients have a higher incidence of significant pulmonary complications. In one study, 16% of patients 65 years and older with isolated blunt chest trauma had some delayed adverse event, defined as pneumonia, ARDS, unanticipated intubation, need to transfer patient to ICU for hypoxemia, and death from pulmonary sequelae.[14]

Patient Education

Return to work or sport depends on the activity involved and the level of pain. Heavy labor and intensive training for athletes with stress fractures are not recommended for the first 3 weeks. When pain is not present at rest, the patient can begin to increase his or her activity level but this should be gradually done. Most rib fractures heal within 6 weeks. Many patients are able to resume daily activities much sooner.[23]

Virtually all nonpathologic rib fractures heal well with conservative management. Some patients are able to return to work within a few days, depending on their occupation.[23]

 

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.

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]

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]

 

DDx

 

Workup

Laboratory Studies

Laboratory studies are generally not useful for evaluation of isolated rib fractures. Consider obtaining urinalysis in cases of lower rib fractures, as hematuria may indicate associated renal injury.[25]  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.

Findings of sternal fracture[8] or scapular fracture[28] should increase suspicion for rib fractures.

Rib radiographs

Obtaining a rib radiograph series remains controversial, as the additional information rarely changes the clinical picture or alters treatment. Rib detail radiographs can be helpful in evaluation of the 1st and 2nd ribs and the 7th through 12th ribs. (See the images below.) Formal plain radiographs can also be useful to document abuse for legal purposes.

Anteroposterior (AP) radiograph of an elderly fema 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.
Right rib radiograph in a 48-year-old male who pre Right rib radiograph in a 48-year-old male who presented with severe right posterior chest wall pain following a fall. This image demonstrates 2 fractures of the right chest wall (white arrows).

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.

Aortic injury, as shown in the image below, 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.

Aortic injury is closely associated with a widenin 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.

Clinicians should obtain a skeletal survey in infants suspected of being abused. Findings consistent with abuse include the presence of multiple rib fractures in various stages of healing.

Bedside ultrasonography

Bedside ultrasonography by emergency physicians has been described and provides rapid diagnosis with no radiation exposure.[30]

Advantages include diagnosis of fracture in unossified bone in children, and diagnosis of other rib fractures that may be missed on plain radiographs. Small preliminary studies suggest that ultrasonography may be more sensitive than chest radiography in detecting rib fractures when physicians who perform the examination are comfortable using the technique.[31, 32, 33, 34]

Ultrasound also detects costal cartilage fractures and costochondral junction fractures better than radiography. Healing fractures with callous formation and sternal fractures may also be sonographically detected.

The technique includes first clinically identifying the site of maximal tenderness, then using a high-frequency 7-MHz to 12-MHz linear transducer. The transducer is placed perpendicular to the long axis of the rib to identify the posterior surface of the rib by its distinct acoustic shadowing and then rotated 90 degrees to detect any discontinuity of cortical alignment, seen as a break in the hyperechoic rib margin.[30]

Other reported but less common sonographic signs suggestive of fracture include the following: a linear acoustic edge shadow posterior to the fracture, a reverberation artifact posterior to the fracture, and the presence of a hypoechoic hematoma. Once a rib fracture is diagnosed, ultrasonography can then be conveniently and reliably used to exclude the likely complications of pneumothorax and hemothorax.[30]

A limitation is that retroscapular ribs and the infraclavicular portion of the first rib are technically inaccessible by sonography. However, these are uncommon sites for rib fractures.[30]

Chest CT scan

Chest CT scan (see the image below) is more sensitive than plain radiographs for detecting rib fractures.[35] The modality can also provide information regarding the number of ribs involved.

Axial computed tomography image of the chest in a Axial computed tomography image of the chest in a patient with both anterior and posterior thoracic injuries. A fracture of the sternum (white arrow) and a posterior left rib fracture (yellow arrow) are present.

If complications from rib fractures are suspected clinically or diagnosed by plain radiographs, a chest CT scan may be helpful to document specific injuries, to characterize extent of injury, and to 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. The reported incidence of concomitant intra-abdominal injuries with lower rib fractures is 20-40%. Abdominal CT has been reported to be particularly important if patients are younger than 55 years, have bilateral rib fractures, and have decreased hematocrit levels.[36]

In a study of rib fractures in clinically diagnosed cases of child abuse, a retrospective analysis of initial and follow-up skeletal surveys and CT scans of 16 patients younger than 12 months found that 17% (18 of 105) of rib fractures were not documented on the initial skeletal survey. Those fractures not originally detected were seen only after follow-up imaging, more than half of which (11/18) were detected on a subsequent CT. Many of these were posterior (43%) or anterior (30%), and 96% were nondisplaced.[37]

Angiography

Because 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.[4] 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.

Bone Scan

A bone scan of the chest wall is the preferred instrument to diagnose rib stress fractures early in the pathologic process. Such fractures typically are not visible on plain films of the chest until very late in their healing, when they develop a visible callus.

Normal costochondral uptake in a child may be intense enough to suggest rib stippling when viewed from a posterior projection.

Any disease or lesion of a rib that results in increased bone turnover may result in positive findings in the ribs.

False-negative results may occur in patients who have recently received iron dextran injections as high levels of iron in the bone marrow interfere with the normal uptake of bone.

MRI

Although MRI is not used as a primary means of detecting rib fractures, displaced or angulated lateral rib fractures as well as posterior rib fractures can be detected by MRI.

Breathing motion can cause artifacts, resulting in nondiagnostic MRIs of anterior rib fractures.

Partial-volume effects may result in a false suggestion of a nondisplaced rib fracture.

 

Treatment

Prehospital Care

Prehospital care should focus on airway maintenance and supplemental oxygen.

Emergency Department Care

The goal of initial ED care is stabilization of the trauma patient and multisystem trauma evaluation.

Respiratory care, including use of incentive spirometry to prevent atelectasis and its complications, is often important. Holding a pillow or similar soft brace against the fracture site reduces discomfort while using the spirometer or when coughing.

Pain control is fundamental to the management of rib fractures to decrease chest wall splinting and alveolar collapse in order to clear pulmonary secretions. Isolated rib fractures, without associated injuries, may be managed on an outpatient basis with oral analgesics, starting with NSAIDs if not contraindicated and progressing to narcotics if not sufficient. A lidocaine patch for pain control has been used, but one study suggests its efficacy is no greater than placebo.[38]  Other options include parenterally administered narcotics titrated to prevent respiratory depression. 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.

Several researchers recommend hospital admission for any patient with 3 or more rib fractures, and ICU care for elderly patients with 6 or more rib fractures. They cite the significant correlation between these findings and serious internal injuries, such as pneumothorax and pulmonary contusion.[39]

Patients with minor rib injuries able to cough and clear secretions may be discharged with adequate analgesic medications. Adequate analgesics are critical to successful outpatient management of rib fractures.[40] In one study, 19% of patients discharged with the diagnosis of rib fracture returned to the ED for unplanned follow-up; the chief complaint was insufficient analgesia (in 56%).[41]  Most patients who will develop complications will do so within 2 weeks, so a follow-up plan within 2 weeks should be made.[41, 42]

Routine follow-up chest x-rays days after the injury are not recommended. They add little besides cost to a careful clinical examination and should be performed only if indicated by clinical findings (eg, unilateral decreased breath sounds suggesting pneumothorax, persistent pain suggesting malunion or nonunion).[43]

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.

One study of patients aged 65 years and older suggests that patients in this age group without risk factors may be safely discharged home. Risk factors are age ≥85 years, initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 of more unilateral rib fractures, or pulmonary contusion. Patients without these risk factors, with isolated blunt chest trauma, did not have an adverse event in this preliminary study (100% sensitivity, 38.5% specificity).[14]

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.

Medical Care

Patients with isolated rib fractures who are unable to cough and clear secretions adequately should be considered for admission for 24-hour observation. Consider admission for patients with underlying lung disease or decreased pulmonary reserve. 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.[14]

Specifically in the age group 65 years and older, consider admission for patients age ≥85 years, or with initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 or more unilateral rib fractures, or pulmonary contusion.[14]  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.[44]  A paravertebral block is only useful for patients with unilateral rib fractures but is associated with a lower rate of systemic hypotension.[45]  [40]

Intercostal nerve blocks provide pain relief without affecting respiratory function, although risks of this procedure include intravascular injection and pneumothorax. The procedure is also limited by the duration of the block and, for patients with multiple rib fractures, the need to perform the procedure at multiple intercostal levels. Intercostal nerve block has been shown to have the advantage of providing dramatically more effective pain control than conventional medications in the initial stage of treatment of patients with thoracic injuries. It is also relatively simple to use; is not associated with neurologic complications due to nausea, vomiting, dizziness, or bleeding; and is not associated with complications from possible misjudgment observed in other measures, such as thoracic epidural injection.[46, 40]

A meta-analysis that included 8 studies (232 patients) did not demonstrate significant benefit of epidural analgesia on mortality, ICU, and hospital length of stay compared with other analgesic modalities in adult patients with traumatic rib fractures. Mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics may be beneficial, although hypotension was significantly associated with thoracic epidural analgesia. Further research and evaluation is needed regarding the benefits and harms of epidural analgesia in this population before being considered as a standard of care therapy.[47]

In a study of epidural analgesia versus paravertebral block for patients with rib fractures using information from the National Trauma Data Bank, neither procedure was found to be more beneficial; however, in patients who did not undergo either procedure, mortality was increased (odds ratio 2.25; 95% confidence interval, 1.14-3.84; P=.002).[40]

Patients with isolated rib fractures who are unable to cough and clear secretions adequately should be considered for admission for 24-hour observation.

Consider admission for patients with underlying lung disease or decreased pulmonary reserve.

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.[14]

Specifically in the age group 65 years and older, consider admission for patients age ≥85 years, or with initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 or more unilateral rib fractures, or pulmonary contusion.[14]

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.[44]  A paravertebral block is only useful for patients with unilateral rib fractures but is associated with a lower rate of systemic hypotension.[45]  Intercostal nerve blocks provide pain relief without affecting respiratory function, although risks of this procedure include intravascular injection and pneumothorax. The procedure is also limited by the duration of the block and, for patients with multiple rib fractures, the need to perform the procedure at multiple intercostal levels.

A meta-analysis that included 8 studies (232 patients) did not demonstrate significant benefit of epidural analgesia on mortality, ICU, and hospital length of stay compared with other analgesic modalities in adult patients with traumatic rib fractures. Mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics may be beneficial, although hypotension was significantly associated with thoracic epidural analgesia. Further research and evaluation is needed regarding the benefits and harms of epidural analgesia in this population before being considered as a standard of care therapy.[47]

In hospitalized patients, an intrapleural catheter placement may also be used for delivery of anesthetics directly into pleural cavity. The catheter used to administer the anesthetic can be placed adjacent a thoracostomy tube at the time of tube placement.[48]

Patient-controlled analgesia pumps have also shown to be useful in hospitalized patients allowing adequate pain relief with minimal inhibition of respiratory drive.

Surgical Care

In a  meta-analysis of 22 studies of patients with rib fractures who underwent open reduction and internal fixation (ORIF),  ORIF was found to achieve lower mortality, shorter duration of mechanical ventilation and hospital length of stay, and a decreased incidence of pneumonia and the need for tracheostomy.[1]

Complications

Complications of rib fracture may include the following:

  • Respiratory failure: The alteration in chest wall mechanics due to multiple rib fractures increases the work of breathing and the patients with multiple rib fractures are at risk for pulmonary fatigue. Respiratory failure can be due to the chest wall injury (eg, flail chest) but is more commonly due to an underlying pulmonary contusion or development of nosocomial pneumonia, especially if superimposed on a preexisting pulmonary condition.[49]

  • Hypoventilation

  • Hypercapnia

  • Hypoxia

  • Atelectasis

  • Pneumonia: Pneumonia is one of the most common complications associated with rib fractures. Pneumonia rates vary depending on the number of fractures and age of the patient. The incidence of pneumonia for all patients hospitalized with one or more rib fractures is about 6%.[49]

  • Damage to underlying visceral organs

  • Pneumothorax (immediate or delayed)[41]

  • Hemothorax (immediate or delayed)[41]

  • Retained hemothorax: Retained hemothorax refers to the presence of blood/clot in the thoracic cavity that persists in spite of thoracostomy drainage. The risk of empyema is increased in patients with retained hemothorax.[50]

  • Aortic injury (immediate or delayed)[51]

  • Pulmonary contusion

  • Intra-abdominal organ injury[25]

Patients with fractured ribs and vital capacity of less than 30% have been found to have a higher rate of pulmonary complications. One study found that every 10% increase in vital capacity was associated with a 36% decrease in likelihood of pulmonary complications. Patients with a vital capacity greater than 50% had a significantly lower rate of pulmonary complications.[52]

First rib fractures have often been associated with serious head injury, cervical spine injury, delayed subclavian vessel thrombosis, aortic aneurysm, tracheobronchial fistula, thoracic outlet syndrome, and Horner syndrome.[7]

A small percentage of rib fractures do not heal even though a fibrous capsule may envelope the fracture. A nonunion may present months to years after injury and can cause discomfort with respiration due to movement of the fracture site. Some patients find the respiratory restriction due to pain quite disabling.

 

Guidelines

Guidelines Summary

The American College of Radiology (ACR) Appropriateness Criteria for rib fracture includes the following[53] :

  • It is usually unnecessary to perform dedicated radiography (in addition to chest radiography) for the diagnosis of in adults after minor trauma.

  • Although the diagnosis of multiple fractures has prognostic implications, there is no evidence that performing dedicated studies, CT, or bone scintigraphy is beneficial, except in the setting where such evaluation is necessary for establishing further care or other investigations (eg, elder abuse, legal documentation).

  • CT, skeletal scintigraphy, and US may be helpful in evaluating selected patients with occult "stress" and in evaluating selected CPR survivors or in situations in which identifying a rib fracture is deemed to be clinically important.

  • Neither clinical examination nor radiography is ideal for the diagnosis of rib fractures. The standard posteroanterior (PA) chest radiograph is specific but not very sensitive for fractures (the supine anteroposterior [AP] radiograph is even less sensitive), and clinical examination is sensitive but not specific. Rib detail radiographs rarely add additional information to the PA film that would change treatment. Similarly, dual-energy chest radiography with bone subtraction imaging has failed to show improved detection when compared with standard radiographs.

  • Multidetector CT is increasingly used as the method of choice for the radiologic evaluation of the traumatized patient. It provides an accurate assessment of fractures and associated internal injuries. CT also provides an accurate means of assessing cartilage fractures, which are typically missed on radiography. However, CT is not usually performed only to evaluate for the presence of rib fractures; rather, it is used to evaluate for other associated complications of trauma. Ultrasound (US) may also be used for depiction of rib fractures or associated costal cartilage injury in the emergency setting.

  • Nuclear medicine bone scans are sensitive but not specific for detection of rib fracture. Bone scans are most commonly used for detection of osseous involvement in systemic processes (eg, metastatic disease) and may result in false-positive diagnosis of malignancy in a patient with rib fractures, although the pattern of tracer uptake can often help differentiate the 2 processes.

 

Medication

Medication Summary

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

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Class Summary

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.

Ibuprofen (Ibuprin, Advil, Motrin)

First-line drug of choice for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which, in turn, decreases prostaglandin synthesis.

Ketoprofen (Oruvail, Orudis, Actron)

For relief of mild to moderately severe pain and inflammation.

Administer small dosages initially to patients with lower body weights, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and observe closely.

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Analgesics

Class Summary

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.

Acetaminophen (Tylenol, Panadol, Paracetamol)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Effective in relieving mild to moderate acute pain; however, has no peripheral anti-inflammatory effects. May be preferred in elderly patients because of fewer GI and renal side effects.

Acetaminophen and codeine (Tylenol #2, Tylenol #3, Tylenol #4)

Combines analgesic effects of a centrally acting opium-derived alkaloid (codeine) and a peripherally acting nonopioid analgesic (acetaminophen). Indicated for treatment of mild to moderate pain.

Hydrocodone and acetaminophen (Vicodin)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for the relief of moderate to severe pain. DOC for aspirin-hypersensitive patients.

Oxycodone and aspirin (Percodan)

Drug combination indicated for relief of moderately severe to severe pain.

Hydrocodone and ibuprofen (Vicoprofen)

Drug combination indicated for the relief of moderate to severe pain.

Morphine

Used to achieve a desired anxiolytic and analgesic effect because easily titrated to desired level of pain control or sedation. Reversed by naloxone.

 

Questions & Answers

Overview

What is a simple rib fracture?

How does the location of the rib fracture affect mortality?

What is the most common mechanism of injury for rib fractures?

What is the role of radiography in the diagnosis of rib fractures?

How is pain managed in patients with rib fracture?

What is the function of the chest wall in rib fractures?

How do rib fractures compromise ventilation?

What is the usual mechanism of rib fracture in motor vehicle accidents?

Where are the ribs most likely to fracture?

Why is the risk of rib fractures lower in children?

What is the prevalence of rib fractures?

How does the prevalence of rib fractures vary by age?

What is the mortality rate for rib fractures?

What is the prognosis of a rib fracture?

What activity restrictions are needed following rib fracture?

Presentation

What should be the focus of history in suspected rib fracture?

Which physical findings suggest rib fracture?

What are common causes of rib fractures?

DDX

What are the differential diagnoses for Rib Fracture?

Workup

What is the role of lab studies in the evaluation of rib fractures?

What is the role of chest radiographs in the evaluation of rib fractures?

What is the role of rib radiographs in the evaluation of rib fractures?

What is the role of bedside ultrasonography in the evaluation of rib fractures?

What is the role of chest CT scan in the evaluation of rib fracture?

What is the role of angiography in the evaluation of rib fracture?

What is the role of bone scan in the evaluation of rib fracture?

What is the role of MRI in the evaluation of rib fracture?

Treatment

What is included in prehospital care of a suspected rib fracture?

What are the initial goals of rib fracture emergency care?

What is the role of CT scans in the emergency management of rib fracture?

When is hospitalization indicated for the treatment of rib fractures?

When should patients be discharged from the hospital following treatment for a rib fracture?

Which specialist consultations are needed for the treatment of rib fracture?

When should inpatient care be considered for patients with rib fracture?

Which patient groups should be receive inpatient care for a rib fracture?

What is the role of epidural analgesia in the treatment of rib fractures?

What are the benefits of epidural analgesia in the treatment of rib fractures?

What is the role of an intrapleural catheter in the treatment of rib fractures?

What is the role of surgery in the treatment of rib fracture?

What are possible complications of a rib fracture?

Guidelines

What are the American College of Radiology (ACR) appropriateness criteria for rib fracture?

Medications

What is the goal of drug treatment for a rib fracture?

Which medications in the drug class Analgesics are used in the treatment of Rib Fracture?

Which medications in the drug class Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in the treatment of Rib Fracture?