Rib Fracture


Article Author:
Kevin Kuo


Article Editor:
Amie Kim


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/4/2019 2:31:12 PM

Introduction

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.[1]

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.[2] 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.[3] 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.[4][5]

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.[6]

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.[7] 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%.[8]

History and Physical

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.[9] Point-of-care ultrasonography can reliably detect rib fractures along with complications of rib fractures such as pneumothorax.[10] 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 / 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.[11] 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.[12] If surgery is necessary, earlier operative intervention leads to better outcomes and also reduction or avoidance for mechanical ventilation.[13]  Additionally, any other underlying injuries such as pneumothorax or hemothorax should be appropriately managed with insertion of a chest tube if indicated.

Differential Diagnosis

  • Rib and chest wall contusion
  • Diaphragmatic injury
  • Hemothorax
  • Pneumothorax
  • Sternal fracture
  • Pulmonary contusion
  • Cardiac contusion
  • Clavicular fracture
  • Flail chest
  • Scapular fracture
  • Pneumomediastinum

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.[14] 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.

Deterrence and Patient Education

Given that rib fractures in the elderly are associated with higher mortality and morbidity, particular attention and resources need to be directed towards fall prevention to reduce the incidence of rib fractures. Studies show that an interdisciplinary team can significantly reduce the risk of falls in the elderly and therefore, clinicians and hospital staff should receive training on how to provide the necessary tools and resources needed to prevent falls.[15]

Enhancing Healthcare Team Outcomes

As with all significant trauma, a team of trained and dedicated professionals including emergency physicians, trauma surgeons, emergency and ICU nurses is requisite for initial evaluation, management, and stabilization. Early identification of potential patient decompensation should receive attention as a team, and possible interventions such as intubation, chest tubes, thoracotomies should be a team discussion to achieve optimal patient care and clinical results. [Level V] For insignificant trauma and simple rib fractures, patients can be safely discharged after evaluation. 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Rib Fracture - Questions

Take a quiz of the questions on this article.

Take Quiz
A patient was diagnosed with a right first rib fracture. On exam, he has pain, weakness, and numbness on his right upper extremity. Symptoms are worse with the elevation of his right arm. Otherwise, the arm is warm, radial pulses are intact, and no significant swelling of the arm is appreciated. Which of the following is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old comes to you with an acute nondisplaced left 6th anterior rib fracture on x-ray. Blood pressure is 130/80, heart rate 80, respiratory rate 16, and the patient has an oxygen saturation of 99% on room air. What is the next step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 16-year-old man is involved in a significant motor vehicle accident. As part of the trauma evaluation, the patient undergoes a CT scan of his chest which showed active extravasation of contrast from the subclavian artery and a massive hemothorax. Which of the following rib fractures is the likely cause of this injury?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 50 year-old male sustained multiple rib fractures after falling. His pain has been poorly controlled with IV NSAIDs and morphine. What is the next step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient sustains an injury to the right lower rib segments nine through twelve. There is a positive focused assessment with sonography (FAST) exam. The patient is in pain but otherwise vital signs are within normal limits. What is the next step in management?

(Move Mouse on Image to Enlarge)
  • Image 3687 Not availableImage 3687 Not available
    Contributed by Gray's Anatomy Plates
Attributed To: Contributed by Gray's Anatomy Plates



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 22-year old mother brings her 2-year-old child to the emergency department. She claims that the child fell at home. Which of the following is highly suspicion for child abuse?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 55-year old postmenopausal female slips on a patch of ice and hits the pavement headfirst. She is found to have fractures of 5 successive ribs on the left but there is no pneumothorax. She is in pain and tachypneic. Her oxygen saturation is 90% at room air. What is the best management for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 78-year-old man is brought in by the ambulance for slip and fall a flight of stairs with obvious injuries to his right torso. He is awake and alert but complaining about pain on his right chest wall. On examination, a small segment of his ribs move inward during inspiration and outward during expiration. He is currently saturating 99% on a 2-liter nasal cannula and breathing at a respiratory rate of 22 breaths per minute. Which of the following is the appropriate next step in the management of his injury?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 30-year-old male walks into the emergency department complaining of pain on his right chest after being assaulted. Vital signs include blood pressure 135/80 mm Hg, heart rate 90 bpm, respiratory rate 16 per minute, saturating at 99% on room air. Physical exam shows tenderness along the right anterior chest wall. Chest X-ray is significant for an isolated 5th rib fracture on the right chest wall without other findings. What is the next step in management for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 70-year-old patient complains of left shoulder pain and left flank pain after being involved in a motor vehicle accident. X-ray shows fractures to the left eighth, ninth, and tenth ribs. What is the next best step in the management of the patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Rib Fracture - References

References

Graeber GM,Nazim M, The anatomy of the ribs and the sternum and their relationship to chest wall structure and function. Thoracic surgery clinics. 2007 Nov;     [PubMed]
Bulger EM,Arneson MA,Mock CN,Jurkovich GJ, Rib fractures in the elderly. The Journal of trauma. 2000 Jun;     [PubMed]
Katrancioglu O,Akkas Y,Arslan S,Sahin E, Spontaneous rib fractures. Asian cardiovascular     [PubMed]
Garcia VF,Gotschall CS,Eichelberger MR,Bowman LM, Rib fractures in children: a marker of severe trauma. The Journal of trauma. 1990 Jun;     [PubMed]
Kemp AM,Dunstan F,Harrison S,Morris S,Mann M,Rolfe K,Datta S,Thomas DP,Sibert JR,Maguire S, Patterns of skeletal fractures in child abuse: systematic review. BMJ (Clinical research ed.). 2008 Oct 2;     [PubMed]
Boele van Hensbroek P,Mulder S,Luitse JS,van Ooijen MR,Goslings JC, Staircase falls: high-risk groups and injury characteristics in 464 patients. Injury. 2009 Aug;     [PubMed]
Iwamoto J,Takeda T, Stress fractures in athletes: review of 196 cases. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association. 2003;     [PubMed]
Pettiford BL,Luketich JD,Landreneau RJ, The management of flail chest. Thoracic surgery clinics. 2007 Feb;     [PubMed]
Assi AA,Nazal Y, Rib fracture: Different radiographic projections. Polish journal of radiology. 2012 Oct;     [PubMed]
Turk F,Kurt AB,Saglam S, Evaluation by ultrasound of traumatic rib fractures missed by radiography. Emergency radiology. 2010 Nov;     [PubMed]
Hwang EG,Lee Y, Effectiveness of intercostal nerve block for management of pain in rib fracture patients. Journal of exercise rehabilitation. 2014 Aug;     [PubMed]
Doben AR,Eriksson EA,Denlinger CE,Leon SM,Couillard DJ,Fakhry SM,Minshall CT, Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. Journal of critical care. 2014 Feb;     [PubMed]
Pieracci FM,Coleman J,Ali-Osman F,Mangram A,Majercik S,White TW,Jeremitsky E,Doben AR, A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures. The journal of trauma and acute care surgery. 2018 Jan;     [PubMed]
Rostas JW,Lively TB,Brevard SB,Simmons JD,Frotan MA,Gonzalez RP, Rib fractures and their association With solid organ injury: higher rib fractures have greater significance for solid organ injury screening. American journal of surgery. 2017 Apr;     [PubMed]
Close J,Ellis M,Hooper R,Glucksman E,Jackson S,Swift C, Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet (London, England). 1999 Jan 9;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of PA-Hospital Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for PA-Hospital Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in PA-Hospital Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of PA-Hospital Medicine. When it is time for the PA-Hospital Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study PA-Hospital Medicine.