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Rib Fracture

By Thomas G. Weiser, MD, MPH

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Patient Education

One or more ribs can be fractured due to blunt chest injury.

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 the elderly, only mild or moderate force (eg, in a minor fall) is required. If ≥ 2 adjacent ribs fracture in 2 separate places, the breaks in each rib result in a flail chest (see Flail Chest).

Pearls & Pitfalls

  • Minor trauma (eg, due to a fall) in the elderly can cause rib fractures that may have fatal consequences.

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 contusion

  • Pneumothorax

  • Hemothorax

  • Tracheobronchial injuries (uncommon)

Complications

Most complications 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 the elderly or patients with multiple fractures. As a result, elderly patients have high mortality rates (up to 20%) due to rib fractures. Young healthy patients and those with 1 or 2 rib fractures rarely develop these complications.

Symptoms and Signs

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

  • Usually chest x-ray

Palpation of the chest wall may identify some fractures. Some clinicians feel clinical evaluation is 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 tests are done to check for concomitant injuries that are clinically suspected.

Treatment

  • Analgesia

  • Pulmonary toilet

Treatment usually requires opioid analgesics, although opioids can also depress respiration and worsen atelectasis. Some clinicians prescribe 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, epidural drug administration or intercostal nerve blocks can be considered.

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 usually be avoided because it constricts respiration and may predispose to atelectasis and pneumonia.

Resources In This Article

* This is the Professional Version. *