(See also Overview of Thoracic Trauma Overview of Thoracic Trauma Thoracic trauma causes about 25% of traumatic deaths in the US. Many chest injuries cause death during the first minutes or hours after trauma; they can frequently be treated at the bedside... read more .)
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 Flail Chest Flail chest is multiple fractures in ≥ 3 adjacent ribs that result in a segment of the chest wall separating from the rest of the thoracic cage; it is a marker for injury to the underlying lung... read more .
Pearls & Pitfalls
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)
Pneumothorax Pneumothorax (Open) Open pneumothorax is a pneumothorax involving an unsealed opening in the chest wall; when the opening is sufficiently large, respiratory mechanics are impaired. (See also Overview of Thoracic... read more (see Pneumothorax [Traumatic] Pneumothorax (Traumatic) Traumatic pneumothorax is air in the pleural space resulting from trauma and causing partial or complete lung collapse. Symptoms include chest pain from the causative injury and sometimes dyspnea... read more and Pneumothorax [Tension] Pneumothorax (Tension) Tension pneumothorax is accumulation of air in the pleural space under pressure, compressing the lungs and decreasing venous return to the heart. (See also Overview of Thoracic Trauma.) Tension... read more )
Tracheobronchial injuries (uncommon)
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 Atelectasis Atelectasis is collapse of lung tissue with loss of volume. Patients may have dyspnea or respiratory failure if atelectasis is extensive. They may also develop pneumonia. Atelectasis is usually... read more and pneumonia Overview of Pneumonia Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and... read more , 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 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 Pulmonary Contusion Pulmonary contusion is trauma-induced lung hemorrhage and edema without laceration. (See also Overview of Thoracic Trauma.) Pulmonary contusion is a common and potentially lethal chest injury... read more ). 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 of Rib Fracture
Treatment of rib fractures usually requires opioid analgesics, although opioids can also depress respiration and worsen atelectasis Atelectasis Atelectasis is collapse of lung tissue with loss of volume. Patients may have dyspnea or respiratory failure if atelectasis is extensive. They may also develop pneumonia. Atelectasis is usually... read more . 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, epidural drug 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 Treatment reference One or more ribs can be fractured due to blunt chest injury. (See also Overview of Thoracic Trauma.) This x-ray of the chest shows multiple fractures to the right ribs (seen on left). Typically... read more ).
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
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.