Initial evaluation and management of rib fractures
- Kristine A Karlson, MD
Kristine A Karlson, MD
- Associate Professor of Community and Family Medicine and Orthopedics
- Dartmouth Medical School
- Section Editors
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health & Science University
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
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".)
CLINICAL ANATOMY AND PHYSIOLOGY
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 . 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).
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- CLINICAL ANATOMY AND PHYSIOLOGY
- MECHANISM OF INJURY
- CLINICAL PRESENTATION AND EXAMINATION
- General fractures
- Stress fractures
- DIAGNOSTIC IMAGING
- Imaging following trauma
- - Chest radiographs
- - Ultrasound
- - Other techniques
- Imaging stress fractures
- INDICATIONS FOR REFERRAL
- INITIAL MANAGEMENT
- Analgesia and monitoring
- Treatment of stress fractures
- FOLLOW-UP CARE
- COMPLICATIONS AND ASSOCIATED INJURIES
- RETURN TO SPORTS AND WORK
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS