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
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).
MECHANISM OF INJURY
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 . 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.
- Gray's Anatomy, Standins S (Ed), Elsevier, New York 2005.
- Love JC, Symes SA. Understanding rib fracture patterns: incomplete and buckle fractures. J Forensic Sci 2004; 49:1153.
- Coris EE, Higgins HW 2nd. First rib stress fractures in throwing athletes. Am J Sports Med 2005; 33:1400.
- Connolly LP, Connolly SA. Rib stress fractures. Clin Nucl Med 2004; 29:614.
- Warden SJ, Gutschlag FR, Wajswelner H, Crossley KM. Aetiology of rib stress fractures in rowers. Sports Med 2002; 32:819.
- Hanak V, Hartman TE, Ryu JH. Cough-induced rib fractures. Mayo Clin Proc 2005; 80:879.
- De Maeseneer M, De Mey J, Debaere C, et al. Rib fractures induced by coughing: an unusual cause of acute chest pain. Am J Emerg Med 2000; 18:194.
- Sinha AK, Kaeding CC, Wadley GM. Upper extremity stress fractures in athletes: clinical features of 44 cases. Clin J Sport Med 1999; 9:199.
- Christiansen E, Kanstrup IL. Increased risk of stress fractures of the ribs in elite rowers. Scand J Med Sci Sports 1997; 7:49.
- Karlson KA. Rib stress fractures in elite rowers. A case series and proposed mechanism. Am J Sports Med 1998; 26:516.
- Lord MJ, Ha KI, Song KS. Stress fractures of the ribs in golfers. Am J Sports Med 1996; 24:118.
- Miller TL, Kaeding CC. Upper-extremity stress fractures: distribution and causative activities in 70 patients. Orthopedics 2012; 35:789.
- Sakellaridis T, Stamatelopoulos A, Andrianopoulos E, Kormas P. Isolated first rib fracture in athletes. Br J Sports Med 2004; 38:e5.
- Eckstein M, Henderson S. Thoracic Trauma. In: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed, Marx JA, Hockberger RS, Walls RM (Eds), Mosby Elsevier, Philadelphia 2006.
- Easter A. Management of patients with multiple rib fractures. Am J Crit Care 2001; 10:320.
- Sirmali M, Türüt H, Topçu S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg 2003; 24:133.
- Al-Koudmani I, Darwish B, Al-Kateb K, Taifour Y. Chest trauma experience over eleven-year period at al-mouassat university teaching hospital-Damascus: a retrospective review of 888 cases. J Cardiothorac Surg 2012; 7:35.
- Westcott, J, Davis, SD, Fleishon, H, et al. Rib fractures. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215 Suppl:637. www.acr.org (Accessed on June 06, 2006).
- Sears BW, Luchette FA, Esposito TJ, et al. Old fashion clinical judgment in the era of protocols: is mandatory chest X-ray necessary in injured patients? J Trauma 2005; 59:324.
- Shuaib W, Vijayasarathi A, Tiwana MH, et al. The diagnostic utility of rib series in assessing rib fractures. Emerg Radiol 2014; 21:159.
- Hoffstetter P, Dornia C, Wagner M, et al. Clinical significance of conventional rib series in patients with minor thoracic trauma. Rofo 2014; 186:876.
- Expert Panel on Thoracic Imaging, Henry TS, Kirsch J, et al. ACR Appropriateness Criteria® rib fractures. J Thorac Imaging 2014; 29:364.
- Hoffstetter P, Dornia C, Schäfer S, et al. Diagnostic significance of rib series in minor thorax trauma compared to plain chest film and computed tomography. J Trauma Manag Outcomes 2014; 8:10.
- Stawicki SP, Grossman MD, Hoey BA, et al. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc 2004; 52:805.
- Bergeron E, Lavoie A, Clas D, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma 2003; 54:478.
- Holcomb JB, McMullin NR, Kozar RA, et al. Morbidity from rib fractures increases after age 45. J Am Coll Surg 2003; 196:549.
- Livingston DH, Shogan B, John P, Lavery RF. CT diagnosis of Rib fractures and the prediction of acute respiratory failure. J Trauma 2008; 64:905.
- Holmes JF, Ngyuen H, Jacoby RC, et al. Do all patients with left costal margin injuries require radiographic evaluation for intraabdominal injury? Ann Emerg Med 2005; 46:232.
- Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures? Injury 2004; 35:562.
- Kara M, Dikmen E, Erdal HH, et al. Disclosure of unnoticed rib fractures with the use of ultrasonography in minor blunt chest trauma. Eur J Cardiothorac Surg 2003; 24:608.
- Rainer TH, Griffith JF, Lam E, et al. Comparison of thoracic ultrasound, clinical acumen, and radiography in patients with minor chest injury. J Trauma 2004; 56:1211.
- Chan SS. Emergency bedside ultrasound for the diagnosis of rib fractures. Am J Emerg Med 2009; 27:617.
- Reissig A, Copetti R, Kroegel C. Current role of emergency ultrasound of the chest. Crit Care Med 2011; 39:839.
- Paik SH, Chung MJ, Park JS, et al. High-resolution sonography of the rib: can fracture and metastasis be differentiated? AJR Am J Roentgenol 2005; 184:969.
- Gupta A, Jamshidi M, Rubin JR. Traumatic first rib fracture: is angiography necessary? A review of 730 cases. Cardiovasc Surg 1997; 5:48.
- Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma 2003; 54:615.
- Middleton C. The causes and treatments of phantom limb pain. Nurs Times 2003; 99:30.
- Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery 2004; 136:426.
- Lazcano A, Dougherty JM, Kruger M. Use of rib belts in acute rib fractures. Am J Emerg Med 1989; 7:97.
- Quick G. A randomized clinical trial of rib belts for simple fractures. Am J Emerg Med 1990; 8:277.
- Kiev J, Kerstein MD. Role of three hour roentgenogram of the chest in penetrating and nonpenetrating injuries of the chest. Surg Gynecol Obstet 1992; 175:249.
- Simon BJ, Chu Q, Emhoff TA, et al. Delayed hemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity. J Trauma 1998; 45:673.
- Misthos P, Kakaris S, Sepsas E, et al. A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma. Eur J Cardiothorac Surg 2004; 25:859.
- Plourde M, Émond M, Lavoie A, et al. Cohort study on the prevalence and risk factors for delayed pulmonary complications in adults following minor blunt thoracic trauma. CJEM 2014; 16:136.
- Lu MS, Huang YK, Liu YH, et al. Delayed pneumothorax complicating minor rib fracture after chest trauma. Am J Emerg Med 2008; 26:551.
- Ashrafian H, Kumar P, Sarkar PK, DeSouza A. Delayed penetrating intrathoracic injury from multiple rib fractures. J Trauma 2005; 58:858.
- Iyoda A, Satoh N, Yamakawa H, et al. Rupture of the descending thoracic aorta caused by blunt chest trauma: report of a case. Surg Today 2003; 33:755.
- Evans G, Redgrave A. Great Britain Rowing Team Guideline for Diagnosis and Management of Rib Stress Injury: Part 2 - The Guideline itself. Br J Sports Med 2016; 50:270.
- Evans G, Redgrave A. Great Britain Rowing Team Guideline for diagnosis and management of rib stress injury: Part 1. Br J Sports Med 2016; 50:266.
- Bansidhar BJ, Lagares-Garcia JA, Miller SL. Clinical rib fractures: are follow-up chest X-rays a waste of resources? Am Surg 2002; 68:449.
- Dwyer MK, Uhl TL. A traumatic pneumothorax as a result of a rib fracture in a college baseball player. Orthopedics 2003; 26:726.
- Kerr-Valentic MA, Arthur M, Mullins RJ, et al. Rib fracture pain and disability: can we do better? J Trauma 2003; 54:1058.
- DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice, 2nd ed, DeLee JC, Drez D Jr., Miller MD (Eds), Saunders, Philadelphia 2002.
- 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