Rib Fracture


Clinical Presentation

  • Because the severe pain that accompanies a rib contusion is indistinguishable from that caused by a fracture, clinical impression is unreliable in identifying a rib fracture. Point tenderness, splinting, and referred pain on chest compression are common physical findings, but they are not specific enough to indicate a fracture. Decreased breath sounds may reflect splinting but could also be a sign of more significant injury (e.g., pneumothorax) and warrant further evaluation with radiographs.

Mechanism of Injury

  • Rib fractures are the most common anatomic deformity resulting from blunt trauma but are rarely life threatening. Whereas blunt trauma to the chest is the most common cause of injury in rib fractures, less common causes include stress from severe or prolonged coughing and overuse stress in certain sports such as rowing, baseball (pitching), and golf. Rib stress fractures are discussed at end of the chapter in greater detail. Rib fractures can result from pathologic processes such as cancers that metastasize to bone such as breast, prostate, and renal cancer.

Imaging

The main reason to obtain a routine posteroanterior
(PA) and lateral chest radiograph is to look for
signs of intrathoracic complications of rib fractures
such as pneumothorax or hemothorax. Although
its role has been called into question, chest radiography
is still standard practice in the emergency
department evaluation of victims of major trauma.1
Trauma patients suspected of having a significant
intrathoracic injury should undergo a computed
tomography (CT) scan of the chest. A follow-up,
two-view chest radiograph is recommended 6 hours
after the initial evaluation to rule out a delayed
hemothorax or pneumothorax.2 After high-energy
injuries, multiple fractures in adjacent ribs usually
occur. A flail chest results when three or more
adjacent ribs fracture in two separate places on the
same rib, creating a free-floating segment. Rib fractures
are often detected coincidentally during the
course of CT evaluation of the traumatized chest.
It is usually unnecessary to obtain dedicated rib
films in addition to a standard chest series when
evaluating a patient with a suspected rib fracture.
Whereas routine chest radiographs demonstrate
major intrathoracic complications of rib fractures, they are insufficient to detect all rib fractures. The
routine chest radiograph allows for an excellent
view of the posterior portion of the ribs above the
diaphragm, but it does not adequately portray the
lateral portion of the ribs. Lateral rib fractures must
be significantly displaced before they can be
detected on a routine chest radiograph. The anterior
and posterior portions of the ribs can be seen
in profile (the best way to see rib fractures) on the
standard PA view. An oblique view of the ribs must
be obtained to view the lateral portion of the ribs.
A rib series is only indicated if suspicion is high for
multiple fractures or pathologic fractures not
apparent on plain radiographs.
A nondisplaced rib fracture is typically seen as
a vertical or oblique fracture line with a slight
offset that is more easily identified at the superior
margin (Figure 18-1). Nondisplaced or minimally
displaced rib fractures may be detected more easily
by looking for the surrounding soft tissue density
of the hematoma that is usually associated with the
fracture (Figure 18-2). Rib fractures are often more
obvious on follow-up radiographs because of
displacement at the fracture margins caused by
respiratory motion (Figure 18-3). Nondisplaced
fractures may only appear as callus at the fracture
site 10 to 14 days after injury.
Ultrasonography has been used to evaluate
rib fractures, but further study is needed to determine
its clinical utility compared to plain
radiographs.

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Indications for Orthopedic Referral
The need for referral or consultation with a specialist
depends on the presence of associated chest
injuries such as airway obstruction, pneumothorax,
hemothorax, cardiac tamponade, or abdominal
organ laceration. Emergency consultation is
required for any patient who is hemodynamically
unstable. Orthopedic consultation is rarely needed
because the majority of rib fracture complications
are pulmonary, vascular, or abdominal.

Initial Treatment.

Emergent Treatment
The acute management of the patient with a rib
fracture depends in large part on whether any complications
have developed. An aggressive search
must be made for the source of life-threatening
injury in a patient who is hemodynamically unstable
after chest trauma. Patients with two or more
rib fractures at the same level are at increased risk
of pneumothorax, hemothorax, and abdominal
organ injury and thus higher morbidity and mortality.
5 The morbidity and mortality risk is even
greater in elderly patients who sustain blunt trauma
with rib fractures.6 All patients with three or more
rib fractures should be hospitalized for observation
and treatment because of the higher risk of complications
in this group.
Nonemergent Treatment
The mainstay of treatment for uncomplicated rib
fractures is pain control. Patients with rib fractures
often require narcotic medication for adequate analgesia in the acute treatment period to avoid
splinting and subsequent atelectasis. A rib belt may
provide additional pain relief by limiting chest
movement, although use of the belt may be uncomfortable
for some patients and compromise breathing,
and use of these devices has not been shown
to have superior outcomes.7,8
Invasive forms of pain control that are often
used in the management of patients with multiple
rib fractures include intercostal nerve block using
local anesthetic agents and epidural analgesia
These methods of analgesia can minimize the use
of narcotics during the acute treatment phase and
allow the patient to perform breathing exercises
that help avoid atelectasis and pneumonia. Consultation
with an anesthesiologist is recommended
if invasive pain control measures are being
considered.
Although delayed intrathoracic complications
are unusual, they can occur during the first few days
after an acute rib fracture. A follow-up clinical
evaluation is warranted in the first 72 hours or at
any time the patient experiences increased difficulty
breathing or other worrisome symptoms to
reassess the patient’s symptoms and condition and
determine the need for further imaging.

Definitive Treatment
No specific treatment has been shown to be superior
in the management of uncomplicated rib fractures.
The vast majority of these injuries heal
without difficulty despite constant respiratory
movement. The intercostal muscles provide natural
protection and relative immobilization during the
healing phase. The primary goal of treatment is
adequate pain relief that allows satisfactory pulmonary
function to prevent basilar atelectasis and
pneumonia. Liberal use of ice, analgesic medication,
and activity restriction are the cornerstones
of treatment. The duration of symptoms varies, but
most rib fractures heal within 6 weeks. Follow-up
radiographs are unnecessary unless indicated by
physical findings (e.g., decreased breath sounds,
severe persistent pain).

Return to Work or Sports
Return to work or sports after a rib fracture depends largely on the patient’s level of pain and the demands of the activity. When pain free at rest,
the patient can begin to increase activity. Restricted
contact activity is advised for at least 3 weeks after
the injury. Use of a rib protector or flak jacket
during contact sports can allow the athlete to
return to competition sooner and should be worn
for 6 to 8 weeks after the injury.

Complications

The more ribs that are fractured, the greater the likelihood
of complications.10 The most common initial
complications are pneumothorax, pleural effusion,
and hemothorax. Delayed complications include
pneumonia, pulmonary contusion, and pulmonary
embolus. Malunion or nonunion are uncommon and
rarely cause symptoms if they do occur. Resection of
the rib or bone grafting should be considered only for
patients with a symptomatic nonunion.

Pediatric Considerations
Accidental rib fractures are rare in infancy and
result from severe trauma. The detection of a rib fracture after a fall or minor trauma should raise
the suspicion of child abuse.11 The ribs are a
common site for skeletal injury in abused children,
and the majority of abuse-related rib fractures are
in children younger than 2 years of age. Children
younger than 14 years of age have more compliant
rib cages than adults. Thus, rib fractures in a
younger child indicate that the child’s chest has
sustained significant trauma.
Squeezing the chest, compressing the front of
the chest, hitting the child from behind, or stepping
on the chest causes injury in abuse-related rib
fractures. Anterior rib fractures are more common
in abuse, and lateral fractures are more common in
nonabuse.12 Inflicted rib fractures usually are nondisplaced
and involve multiple sequential ribs.
When child abuse is suspected, the addition of
oblique views or a bone scan is warranted because
rib fractures are highly associated with abuse, and
identifying such fractures with routine chest radiographs
is difficult.