Rib Fracture

Pain is severe, is aggravated by movement of the trunk (including coughing or deep breathing), and lasts for several weeks to months. The affected ribs are quite tender to palpation and sometimes the clinician can detect crepitance over the affected rib as the fracture segment moves during palpation.

• Chest radiograph

• For suspected intrathoracic injury, CT

Some clinicians consider a diagnosis based solely on history and physical examination to be adequate in healthy patients with minor trauma. Usually, chest radiographs are also performed sometimes with specific rib views. However, chest radiograph has only a 50% sensitivity for detecting rib fracture (1). For a patient with possible multiple rib fractures, appropriate care can usually be provided without identifying all rib fractures.

Rib Fractures (Radiograph)

Image

This cheat radiograph shows multiple fractures to the right ribs (seen on left).

SCIENCE PHOTO LIBRARY

In patients with significant blunt trauma, chest radiograph is typically performed as an initial study to check for concomitant injuries (eg, pneumothorax, pulmonary contusion). Chest CT is more sensitive than chest radiograph for detecting rib fractures and is performed if rib fracture is suspected and chest radiograph is normal or if additional injuries are suspected. Additional imaging modalities may be required if pathologic rib fracture is possible.

• Analgesia

• Respiratory physiotherapy

• Surgical stabilization

Treatment of rib fractures usually requires adequate analgesia to ensure effective inspiratory effort and lung expansion to prevent complications such as atelectasis and pneumonia. Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment; acetaminophen may be taken concurrently if needed. Muscle relaxants may also be helpful. Immobilization of the ribs that constricts respiration should be avoided. If patients cannot cough or breathe deeply despite oral or IV analgesics, epidural administration or intercostal nerve blocks can be considered. Opioids are used only if pain is not controlled with nonopioid medications; doses should be titrated to avoid respiratory suppression or increasing Treatment of rib fractures usually requires adequate analgesia to ensure effective inspiratory effort and lung expansion to prevent complications such as atelectasis and pneumonia. Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment; acetaminophen may be taken concurrently if needed. Muscle relaxants may also be helpful. Immobilization of the ribs that constricts respiration should be avoided. If patients cannot cough or breathe deeply despite oral or IV analgesics, epidural administration or intercostal nerve blocks can be considered. Opioids are used only if pain is not controlled with nonopioid medications; doses should be titrated to avoid respiratory suppression or increasingatelectasis.

Patients are hospitalized if they have ≥ 3 fractures or underlying cardiopulmonary insufficiency. In a large retrospective cohort study, risk factors for requiring intensive care unit admission in patients ≥ 65 years old included: chronic renal failure, simple pneumothorax, sternal fracture, drug use disorder, and emergency department oxygen requirement or oxygen saturation < 95% (1).  

To minimize pulmonary complications, respiratory physiotherapy after rib fracture includes early mobilization, deep breathing exercises, incentive spirometry, supported coughing, and frequent position changes (2). 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.

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 (3, 4.