1.

Rib Fracture
Rib fractures occur when a significant enough force directed at the rib causes a
break. There are a total of 12 pairs of ribs in the thoracic region. The first seven ribs
attach anteriorly to the sternum and posteriorly to the spinal column. Rib numbers 8
through 10 attach similarly but connect to the costal cartilage of the sternum anteriorly.
Ribs 11 and 12 have the name of “floating” ribs as they only attach posteriorly but do
not attach anteriorly. Underneath each rib lies the intercostal nerve, artery, and veins
which supply to blood supply and innervation. The ribs function to protect the
underlying organs and structures of the thoracic cavity. Any rib fracture should warrant
a thorough evaluation of any concomitant injury, including lungs, heart, kidney, spleen,
liver, and neuro-vasculature.

Epidemiology

The incidence and prevalence of rib fractures depend on the injury and the
severity of the trauma. Children are less likely to sustain rib fractures than adults due to
their more elastic ribs. The elderly tend to be more prone to rib fractures than younger
individuals, with higher mortality and morbidity.

Etiology

Rib fractures can be traumatic or atraumatic. Most rib fractures are due to
direct penetrating or blunt trauma to the chest. Ribs 1 through 3 are the hardest to break
and signify a significant degree of trauma if fractured. Ribs 4 through 10 are typically
the most vulnerable while ribs 11 through 12 are more mobile and therefore more
difficult to break. In the elderly, falls are a common etiology of rib fractures and are
associated with higher mortality and morbidity than younger patients. Rib fractures may
also be pathologic as a result of cancer metastasis from other organs. Through repetitive
stress and microtrauma, athletes can develop rib fractures with chronic use.
Spontaneous rib fractures can also occur due to severe cough and are more likely to
occur in those with osteoporosis or underlying lung disease. Because children tend to
have more elastic ribs than adults do, children are less likely to sustain rib fractures.
Therefore, children with rib fractures is a sign of significant trauma and should warrant
an investigation of possible child abuse.

Pathophysiology

Rib fractures can occur from either direct penetrating or blunt trauma. Athletes
can also develop specific patterns of stress fractures depending on their sport. The most
feared complication of rib fractures is the flail chest where three or more rib fractures
at two points on the involved ribs, creating a floating rib segment and causes this
segment to move paradoxically with the rest of the chest wall. The mortality rate of flail
chest is between 10% to 15%.

History and Physical Examination

Most isolated rib fractures are diagnosable through a clinical exam. Typically,
patients will provide a history of recent blunt or penetrating thoracic trauma and pain at
that site. They may also exhibit decreased ability to perform full inspiration due to pain.
The physical exam may reveal chest wall bruising, along with bony tenderness to
palpitation or crepitus. Any vital sign abnormalities such as hypoxia, tachypnea, or
significant respiratory distress should undergo further evaluation of other possible
injuries such as pneumothorax, hemothorax, cardiac and pulmonary contusions. Lower
rib segment injuries should undergo assessment for kidney, liver, and spleen. Any
patient with paradoxical chest wall movement or suspicion for multiple rib fractures
should be evaluated for flail chest and managed accordingly.

Evaluation

Rib fractures can be diagnosed clinically based upon history and physical
exam without imaging. Dedicated rib x-ray series are typically not necessary due to the
benign clinical course of isolated rib fractures. If there is suspicion for multiple rib
fractures or significant trauma with underlying organ damage, imaging can be the next
step. However, chest radiographs are limited and can only diagnose about 50% of
isolated rib fractures. Point-of-care ultrasonography can reliably detect rib fractures
along with complications of rib fractures such as pneumothorax. Chest computed
tomography (CT) scan is the gold standard of detecting rib fractures, although the
fractures detected may not be clinically significant. The utility of chest CT during
evaluation has more importance in the general assessment of trauma for other injuries.

Treatment and Management

For simple, isolated rib fractures, conservative therapy is usually adequate

which includes appropriate analgesia, rest, and ice. The use of an incentive spirometer
should be encouraged to prevent pulmonary atelectasis and splinting. Intercostal nerve
blocks can also be applied to aid in pain control. Rib taping is no longer the
recommended treatment as it can impede inspiratory effort. When conservative
management fails or for more severe rib fractures, surgical stabilization can be an
option. Typical indications for surgical management include rib fracture nonunion,
chest wall deformity or defect, refractory rib fracture pain causing respiratory failure,
and flail chest. If surgery is necessary, earlier operative intervention leads to better
outcomes and also reduction or avoidance for mechanical ventilation. Additionally, any
other underlying injuries such as pneumothorax or hemothorax should be appropriately
managed with insertion of a chest tube if indicated.

Prognosis

Depending on the severity of the trauma sustained and degree of pain, rib
fractures may be managed either outpatient or inpatient. Isolated rib fractures tend to
heal well and do not need any further interventions beyond pain control, rest, and ice.
Multiple rib fractures, displaced rib fractures, or those with underlying concomitant
injuries may require inpatient monitoring for respiratory failure or surgical correction.
Elderly individuals with rib fractures tend to have a higher mortality rate than younger
individuals and may require closer monitoring.

Complications

The most severe complications related to rib fractures are the flail chest and
damage to the underlying structures. Solid organ injuries associated with rib fractures
include liver injuries and splenic injuries. Typically, the higher the rib fracture is within
the thoracic cage, the more likely it is to cause a liver or splenic injury. Particular
attention needs to be paid for the patient's respiratory status, as rib fractures may cause
the patients to go on and develop acute respiratory failure due to poor respiratory efforts
and may need mechanical ventilation and surgical stabilization.