section name header

Basics ⬇

Author: Robert J.Baker, MD, PhD, FAAFP, FACSM

Description

  • Usually the result of acute blunt trauma, especially in contact sports
  • Rib fractures can also result from rowing, swinging golf clubs, and throwing.
  • Stress fractures can occur as a result of chronic overuse of the upper body.
  • Fractures may be complete, incomplete, or stress related.
  • Rib fractures may often be associated with other fractures, soft tissue injuries, and deep organ trauma.

Epidemiology

  • Isolated fractures of the upper four ribs are rare because they are well protected by the shoulder complex (1,2)[B].
    ALERT
    When injury occurs, trauma can be significant enough to fracture other bones of the shoulder, and injury to the deep organs such as lungs, heart, bronchus, blood vessels, and/or esophagus must be considered (2)[C].
  • Blunt trauma to the lower eight ribs commonly results in fractures, most commonly in contact sports, such as football, hockey, and rugby (2,3)[C].
  • Forceful contraction, usually against a significant amount of resistance, of muscles with an attachment to the ribs may result in incomplete, complete, or avulsion fractures of the ribs (2,3)[B].
  • Chronic stress of upper body muscles, which attach to the ribs, can result in stress fractures of the ribs; commonly seen in rowing, tennis, golf, gymnastics, and baseball (2,3)[B]
  • 1st rib fractures have been reported as a result of falling on an outstretched arm as well as direct trauma; 1st rib stress fractures also reported in the literature (1,2,4,5)[B]
  • Avulsion fractures of the lower three floating ribs often occur at the attachment of the external oblique muscles; known to occur in baseball pitchers and batters (6)[B]
  • Multiple rib fractures occur in high-impact trauma such as automobile, motorcycle, mountain biking, and bicycle racing (2,6)[B].
  • Rib fractures are more common in adults compared to children due to the relative inelasticity of the adult chest wall compared to children (1,7)[C].

Etiology and Pathophysiology

  • There are 12 pairs of ribs, the first 7 of which articulate both posteriorly with the spine and anteriorly with the sternum.
  • 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.
  • Most acute rib fractures occur as a result of direct trauma, either blunt or penetrating missile (i.e., ball, gunshot) (6)[C].
  • Relative long, thin shape of the rib predisposes to fractures. Common specific location is posterior lateral bend (8,9)[C].
  • Because of the rib’s thin bony structure compared to other long bones, fracture may occur earlier due to pathologic causes (8,9,10)[C].
  • Because there are multiple muscle attachments of the rib to the neck and upper extremities, stress can lead to fatigue fractures of the ribs (8,9)[B]. The 1st rib is unique in that the scaleni insert onto it, and it therefore is exposed to stresses from the action of these neck muscles.
  • Superior three pairs of ribs protected by the scapula, clavicle, and soft tissue less likely have isolated fractures. This significant force increases the potential for injury to major vessels and lung parenchyma.
  • The inferior “floating” ribs are relatively mobile and more susceptible to injury from blunt trauma.
  • The ribs act as a unit during respiration, moving in the anteroposterior (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).

Risk-Factors

  • Contact and collision sports such as football, hockey, boxing, wrestling, rugby, and soccer (1,8,9)[A]
  • As with any trauma, injuries can be more severe in athletes unprepared, either from lack of conditioning or contact from the back or blind side.
  • Stress fractures of the ribs more likely to occur in sports with increased upper body demands such as golf, rowing, gymnastics, baseball, tennis, racquet sports, and weight lifting. Overuse and poor technique can contribute to rib stress fractures (8,9)[B].
  • Other predisposing factors include a history of bone or joint disease, bone tumors, metastatic cancer, poor nutrition, and calcium deficiency (1,2,6,7)[C].

Commonly Associated Conditions

Organ injuries that may occur with acute rib fractures include:

Diagnosis ⬆ ⬇

History

  • Acute rib fracture usually presents after chest trauma; can result from a fall on an outstretched arm
  • Often, the pain may be localized to one or two ribs (3)[C].
  • The patient can frequently reproduce or exacerbate the pain by taking a deep breath.
  • Athletes may experience the sensation of having “the wind knocked out of them.”
  • Athlete may recall feeling a “pop” when the trauma occurred.
  • Athlete may complain of abdominal pain if the lower (11th and 12th) ribs are involved.
  • Stress fractures usually occur in elite athletes who train intensely. These fractures tend to be more gradual in onset (7,8)[C].
  • Rib stress fractures present with a gradual onset of activity-related chest wall pain, similar to stress fractures of other bones. Often the pain first occurs only with the inciting activity (e.g., rowing, swinging a golf club, throwing), then progresses to pain with deep breathing or simple movements, such as rolling over in bed or reaching overhead (7,8)[B].

Physical Exam

  • Localized pain, swelling, or ecchymosis may be present over the involved rib(s).
  • Palpable deformity may be present in complete displaced fracture.
  • Pain generally exacerbated by deep inspiration and may result in shallow, rapid breathing
  • An auscultated click caused by movement of the rib fracture and can be heard with a stethoscope placed over the fracture site.
  • Pain aggravated by coughing and sneezing
  • Other symptoms, such as increasing shortness of breath, increasing pain, cyanosis, and subcutaneous emphysema, may indicate serious life-threatening conditions requiring emergent attention.
  • With significant chest trauma, a thorough cardiopulmonary examination must be performed to evaluate for complications or associated injuries (1,2)[B].
  • If trauma occurred to the upper chest, special attention should be given to the neck, shoulders, and major vessels (2,3)[B].
  • If trauma occurred to the lower chest, a thorough abdominal examination should be performed to rule out injury to the liver, spleen, gastrointestinal (GI) tract, and kidneys (1,2)[C].
  • Diminished breath sounds may reflect splinting from the pain of a simple chest wall contusion or the presence of significant injury (e.g., pneumothorax, hemothorax, or pulmonary contusion).

Differential Diagnosis

  • Rib/chest wall contusion
  • Muscle strain
  • Rupture of pectoralis major
  • Costochondral separation/sprain
  • Sternal fracture (anterior)
  • Intervertebral joint/disc injury
  • Apophyseal joint sprain
  • Costovertebral joint sprain
  • Scheuermann disease (posterior)
  • Other causes of chest pain, such as cardiac causes, peptic ulcer disease, gastroesophageal reflux disorder, pneumothorax, pulmonary embolism, asthma, pleurisy, herpes zoster

Diagnostic Tests & Interpretation

  • Standard posteroanterior (PA) and lateral chest radiographs are adequate to identify some rib fractures, but overall sensitivity is poor (1,2,7)[C].
  • Dedicated rib series includes oblique views of the chest wall not included with a standard chest series.
  • Clinicians can base their diagnosis and management on plain radiographs and clinical findings, and a rib series is unnecessary (1,2)[C].
  • In the case of pathologic fractures, other blood work, such as complete blood count (CBC), comprehensive metabolic panel, and isoenzymes of alkaline phosphatase, may be directed by history and physical exam (1,2,3)[B].
  • Other than in cases of complications, continued pain, and poor healing, routine repeat films are not necessary.
  • A bone scan of the chest wall is the preferred study to diagnose rib stress fractures early in the pathologic process (8,9)[C].
  • Magnetic resonance imaging (MRI): Oblique orientation of the ribs and the difficulty with numbering them on axial or coronal scanning can make MRI more difficult to interpret (9,10)[C].
  • With upper thoracic rib fractures, arteriography is indicated if there is evidence of vascular insufficiency, hemorrhage, or concomitant brachial plexus injury; marked displacement of the rib fragments; fractures of the scapula, vertebrae, or sternum; widening of the mediastinum; left apical cupping; or downward displacement of the left main stem bronchus (1,2,3)[B].

Treatment ⬆ ⬇

General Measures

  • Treatment is generally supportive.
  • Pain control is the cornerstone of treatment and may be required for up to 3 to 6 wk after injury.
  • Ice and nonsteroidal anti-inflammatory drugs (NSAIDs) may control symptoms, but stronger oral pain medications may be rarely indicated.
  • Local intercostal nerve blocks remain an option if other pain control techniques fail (1,2)[B].
  • Epidural anesthesia is also an option for pain control (1,2)[C].
    ALERT
    Strapping or a chest binder has been advocated to help with pain. Caution should be exercised because immobilization techniques may result in inhibition of deep breathing, leading to atelectasis and possibly pneumonia (1,6)[C].
  • If immobilization is deemed necessary for comfort, its use should be minimized.
  • Rib stress fractures are treated similarly to other low-risk stress fractures: with restriction of the inciting activity for 4 to 6 wk, followed by a gradual return to the activity as tolerated.
  • Rehabilitation should include proper mechanics and eliminating training errors to avoid recurrence of rib stress fractures (9,10)[C].

Medication

  • For isolated injuries, generally begin treatment with NSAIDs without opioids (1,2)[B].
  • For more severe injuries, and if ventilation is compromised, admission and invasive treatments such as intercostal nerve blocks may be indicated (1,2,3)[C].

Additional Therapies

  • For stress fractures, biomechanics of their upper thoracic and shoulder areas based on sport should be evaluated and corrected if necessary (2)[C].
  • Use of incentive spirometry can prevent atelectasis and its complications.
  • Rib belts or binders are not recommended because they compromise respiratory function.

Surgery/Other Procedures

  • Need for surgery is rare in cases of isolated rib fractures (1)[C].
  • Exception is in the case of flail chest. Open reduction and internal fixation may be required (1,2,3)[C].
  • Surgical fixation may be of benefit with chest wall deformity, flail chest, or symptomatic nonunion.
  • Suspected internal injuries associated with rib fractures should be referred for possible surgical repair.
  • Chronic pain due to recurrent stress fracture, nonunion, or recurrent dislocation or subluxation may improve with surgical excision of the involved rib (10)[B].

Ongoing Care ⬆ ⬇

Follow-up Recommendations

  • Pain from rib fractures can be severe for several days following the injury.
  • The athlete should be encouraged to continue activities as tolerated, except for contact sports (7)[C].
  • Contact should be limited for the first 3 wk following injury. Consider rib protection in contact sports after return (8)[C].
  • Most rib fractures heal within 6 to 8 wk.
  • Monitor regularly for signs of delayed complications (8)[B].
  • Delayed injuries from isolated rib fractures sustained during blunt trauma occur infrequently.
  • A follow-up examination 6 to 8 wk after the injury is reasonable to assess the patient, if they are unable to return to sports or work by that time.

Patient Education

  • Athletes should be educated when to follow up, especially if they experience fever, chills, worsening pain, dizziness, light-headedness, fatigue, persistent cough, or respiratory distress.
  • Athletes should be educated that it is common to have significant pain. They should not be reluctant to take pain medication early on. This allows for more normal breathing and less chance of complications like pneumonia (8)[C].
    ALERT
    Signs of injuries due to rib fractures (e.g., pneumothorax, pulmonary contusion) may be delayed for hours or days, and all discharged patients must be given precise instructions about signs of injury to watch for and told to return to the emergency department (ED) immediately should any such sign appear (1,2)[B].
  • Educate the athlete in the role and use of “incentive spirometry.”
  • For a stress fracture, avoid the activity that caused your stress fracture for 4 to 6 wk and slowly restart that activity.
  • Avoid smoking. A fracture can take longer to heal if you smoke.

Prognosis

  • Intensive training for athletes with stress fractures is not recommended for at least the first 3 wk.
  • Athletes can gradually increase activity as pain permits for isolated rib fractures.
  • Full healing usually takes 6 to 8 wk; however, athletes may return to participation in noncontact sports when pain free.
  • Early return to contact sports may be possible prior to 6 wk if pain is controlled, and the area can be protected adequately until full healing occurs (10)[C].

Complications

  • Nonunion of the ribs is rare in general. Symptomatic nonunion can occur and would be an indication for surgery (4,8)[B].
  • Pseudoarthrosis of the 1st rib is described in the literature and has been a cause for discontinued participation (4,8,10)[B].
  • Early and adequate pain relief is essential to avoid complications from splinting and atelectasis, primarily pneumonia.
  • Significant complications may include pneumothorax, pulmonary contusion, pneumonia, and intercostal hemorrhage.

References ⬆ ⬇

  1. 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(1):133–138.
  2. Brasel KJ, Moore EE, Albrecht RA, et al. Western trauma association critical decisions in trauma: management of rib fractures. J Trauma Acute Care Surg. 2017;82(1):200–203.
  3. Chien CY, Chen YH, Han ST, et al. The number of displaced rib fractures is more predictive for complications in chest trauma patients. Scand J Trauma Resusc Emerg Med. 2017;25(1):19.
  4. Khadavi MJ, Fredericson M. Chest pain in athletes from personal history section (musculoskeletal causes). Curr Sports Med Rep. 2015;14(3):252–254.
  5. Shulzhenko NO, Zens TJ, Beems MV, et al. Number of rib fractures thresholds independently predict worse outcomes in older patients with blunt trauma. Surgery. 2017;161(4):1083–1089.
  6. Murphy CE IV, Raja AS, Baumann BM, et al. Rib fracture diagnosis in the Panscan era. Ann Emerg Med. 2017;70(6):904–909.
  7. Reissig A, Copetti R, Kroegel C. Current role of emergency ultrasound of the chest. Crit Care Med. 2011;39(4):839–845.
  8. Chapman BC, Overbey DM, Tesfalidet F, et al. Clinical utility of chest computed tomography in patients with rib fractures CT chest and rib fractures. Arch Trauma Res. 2016;5(4):e37070.
  9. Sakellaridis T, Stamatelopoulos A, Andrianopoulos E, et al. Isolated first rib fracture in athletes. Br J Sports Med. 2004;38(3):e5.
  10. D’Ailly PN, Sluiter JK, Kuijer PP. Rib stress fractures among rowers: a systematic review on return to sports, risk factors and prevention. J Sports Med Phys Fitness. 2016;56(6):744–753.

Clinical Pearls ⬆

  • In most cases of isolated rib fractures, simple chest films are all that are required. Dedicated rib series may also be obtained based on clinical findings.
  • Patients should continue to be as active as they can tolerate and may use NSAIDs or acetaminophen for pain for isolated fractures.
  • Multiple rib fractures correlate more closely with serious intrathoracic and intra-abdominal injuries. Fractures of superior ribs (numbers 1 to 3) reflect trauma involving significant force and the potential for injury to major blood vessels and lung parenchyma.
  • Displaced fractures increase the risk of internal injury and delayed bleeding and generally warrant admission.
  • Rib stress fractures are treated with restriction of the inciting activity for 4 to 6 wk, followed by a gradual return to the activity as tolerated.
  • Virtually, all rib fractures heal well with conservative management, and follow-up chest radiographs are unnecessary, unless indicated by clinical symptoms.