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Initial evaluation and management of rib fractures

Kristine A Karlson, MD
Section Editors
Patrice Eiff, MD
Maria E Moreira, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


Rib fractures are common injuries, which occur most often following blunt thoracic trauma but can also result from severe coughing, athletic activities (eg, rowing, swinging golf clubs, throwing), and nonaccidental trauma (ie, child abuse). Concomitant injuries and complications range from mild discomfort to life-threatening conditions, such as pneumothorax, splenic laceration, and pneumonia.

This topic will review the evaluation and management of isolated rib fractures, including stress fractures, not involving intrathoracic injury. Discussions of the in-patient management of multiple rib fractures, blunt and penetrating thoracic trauma, and stress fractures generally are found separately. (See "Inpatient management of traumatic rib fractures" and "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults" and "Overview of stress fractures".)


The chest wall consists of 12 pairs of ribs, the first seven of which articulate both posteriorly with the spine and anteriorly with the sternum (figure 1 and figure 2). Ribs 8 to 10 attach anteriorly to the costal cartilage. The lowest two ribs are "floating" and do not connect anteriorly [1]. Immediately below each rib travels its neurovascular bundle, including the intercostal vein, artery, and nerve.

The first rib is unique in that the scaleni insert onto it, and it therefore is exposed to stresses from the action of these neck muscles. The superior ribs (numbers 1 to 3) are relatively protected by the scapula, clavicle, and soft tissue, while the inferior "floating" ribs are relatively mobile. Therefore, the more vulnerable middle ribs (numbers 4 to 10) are most susceptible to injury from blunt trauma. Fractures of superior ribs reflect trauma involving significant force and the potential for injury to major vessels and lung parenchyma.

The ribs act as a unit during respiration, moving in the anterior-posterior (AP) and coronal planes. This concerted rib motion, in addition to the actions of the diaphragm and the intercostal muscles, enables inspiration (by increasing intrathoracic volume and decreasing intrathoracic pressure) and expiration (by decreasing intrathoracic volume and increasing intrathoracic pressure).


Most rib fractures are caused by direct trauma to the chest wall. This can occur from blunt (eg, motor vehicle crash) or penetrating (eg, gunshot) trauma. A single blow may cause rib fractures in multiple places. Traumatic fractures most often occur at the site of impact or the posterolateral bend, where the rib is weakest. Both displaced and nondisplaced fractures can be seen in adults and children [2]. Due to the greater pliability of children's ribs, greater force is required to produce a fracture.

Rib fractures may be pathologic. Cancers that metastasize to bone (eg, prostate, breast, renal) frequently become apparent in a rib. Ribs are relatively thin compared with major long bones and are more likely to fracture when invaded by a metastatic lesion.


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Literature review current through: Sep 2016. | This topic last updated: Jul 5, 2016.
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