One or more ribs can be fractured due to blunt chest injury.
(See also Overview of Thoracic Trauma.)
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Typically, rib fractures result from blunt injury to the chest wall, usually involving a strong force (eg, due to high-speed deceleration, a baseball bat, a major fall); however, sometimes in older patients, only mild or moderate force (eg, in a minor fall) is required. If ≥ 3 adjacent ribs fracture in 2 separate places, the broken segment results in a flail chest.
Pearls & Pitfalls
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Concomitant chest injuries may occur, including
Aortic, subclavian, or cardiac injuries (uncommon but can occur with high-speed deceleration, particularly if rib 1 or 2 is fractured)
Splenic or abdominal injuries (with fractures of any of ribs 7 through 12)
Pulmonary laceration or pulmonary contusion
Pneumothorax (see Pneumothorax [Traumatic] and Pneumothorax [Tension])
Tracheobronchial injuries (uncommon)
Complications
Most complications from rib fractures result from concomitant injuries. Isolated rib fractures are painful but rarely cause complications. However, inspiratory splinting (incomplete inspiration due to pain) can cause atelectasis and pneumonia, especially in older patients or patients with multiple fractures. As a result, older patients have high mortality rates (up to 20%) when presenting with multiple rib fractures. Young healthy patients and those with 1 or 2 rib fractures rarely develop these complications.
Symptoms and Signs of Rib Fracture
Pain is severe, is aggravated by movement of the trunk (including coughing or deep breathing), and lasts for several weeks. The affected ribs are quite tender; sometimes the clinician can detect crepitance over the affected rib as the fracture segment moves during palpation.
Diagnosis of Rib Fracture
Usually chest x-ray
Palpation of the chest wall may identify some rib fractures. Some clinicians feel history and physical examination are adequate in healthy patients with minor trauma. However, in patients with significant blunt trauma, a chest x-ray is typically done to check for concomitant injuries (eg, pneumothorax, pulmonary contusion). Many rib fractures are not visible on a chest x-ray; specific rib views can be done, but identifying all rib fractures by x-ray is usually unnecessary. Other diagnostic tests, such as CT scan, are done to check for concomitant injuries that are clinically suspected.
Treatment of Rib Fracture
Analgesia
Pulmonary hygiene
Surgical stabilization
Treatment of rib fractures usually requires opioid analgesics, although opioids can also depress respiration and worsen atelectasis. Some clinicians prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) simultaneously.
To minimize pulmonary complications, patients should consciously and frequently (eg, hourly while awake) breathe deeply or cough. Holding (essentially splinting) the affected area with the flat palm of the hand or a pillow can minimize the pain during deep breathing or coughing. Patients are hospitalized if they have ≥ 3 fractures or underlying cardiopulmonary insufficiency. Immobilization (eg, by strapping or taping) should usually be avoided; it constricts respiration and may predispose to atelectasis and pneumonia. If patients cannot cough or breathe deeply despite oral or IV analgesics, epidurals administration or intercostal nerve blocks can be considered.
Select patients may benefit from surgical stabilization of rib fractures, particularly for flail chest with respiratory failure or ongoing chest wall instability, deformity, or pain due to nonunion or malunion (1, 2).
Treatment references
1. Kasotakis G , Hasenboehler EA, Streib EW, et al: Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 82(3), 618-626, 2017. doi: 10.1097/TA.0000000000001350
2. Dehghan N, Nauth A, Schemitsch E, et al: Operative vs nonoperative treatment of acute unstable chest wall injuries: A randomized clinical trial. JAMA Surg 157(11):983, 2022. doi: 10.1001/jamasurg.2022.4299
Key Points
Morbidity results from underlying lung, splenic, or vascular injury or development of pneumonia due to splinting, rather than rib fractures themselves.
X-ray identification of all rib fractures is usually unnecessary.
Pain can be severe and last for weeks, usually requiring opioid analgesics.
Strapping or taping should not be used because it constricts respiration and may predispose to atelectasis and pneumonia.
