Rib Fracture

The severity of complications is directly proportional to the number of affected ribs or the types of ribs which have been fractured. Depending on the quantity and which ribs are affected, underlying organs may be affected.

Complications include damage to the aorta, which could be torn or punctured, following a fracture occurring in the first three ribs. Damage in the middle ribs can cause a punctured lung and therefore development of a pneumothorax. Injury to the bottom ribs can cause solid organ injury to the spleen, kidneys, and liver.

The presentation of patients with rib fractures includes pain experienced with movement, breathing or coughing. Rib fracture has significant effects on ventilation. Dyspnea, pleuritic chest pain, and hypoxia are commonly seen.

Complications include a severe condition associated with rib fracture, flail chest can occur. It is secondary to multiple ribs fractured at numerous sites, in which a segment of the rib breaks off. Pulmonary contusion is another complication. In severe cases a life threatening condition, adult respiratory distress syndrome (ARDS), can develop. 

All patients with blunt trauma to the chest undergo imaging. Furthermore, index of suspicion for rib fractures and other injuries should be high. Diagnosis of rib fractures and associated injuries can be made by the following tests:

X-ray

In addition to detecting fractures, anteroposterior and lateral chest X-rays can visualize other associated injuries such as lung contusion, hemothorax, atelectasis, pneumothorax and pneumonia. The simple fractures appear as cracks while displaced ones show two misaligned segments. 

Computed tomography 

These are more sensitive than chest x ray for detection of fractures [9]. These scans also help diagnose lung injuries such as pulmonary contusion and pneumothorax. 

Urinalysis

Necessary to find possible hematuria, if kidney injury due to lower rib fractures has occurred [10]. 

Arterial blood gas

In the case of pulmonary contusion or other lung injuries.

Other special consideration

Spontaneous fractures in patients with a history of malignancy should be suspected. For spontaneous fractures in patients with no prior malignancy, a detailed history and family history should be obtained along with a physical exam. The workup would include imaging such as CT scan and/or MRI to determine primary versus metastasis.

In emergency care, time and accuracy are critical. The primary goal is to stabilize the patient with coordination by the medical staff in trauma evaluation. Airway evaluation and respiratory care are crucial. Rapid evaluation and treatment are key. 

Pain control

Stable patients breathing independently usually require pain control. The common drugs are morphine and oral analgesics such as NSAIDs. Adequate control of pain is essential to enable the patient to breathe normally and prevent respiratory splinting.

Surgical procedures

In the event of a pneumothorax, the trauma or the general surgery team is needed in conjunction with the emergency staff to perform a thoracotomy. In the cases of a hemothorax, drainage is needed. Inpatients should be monitored closely with imaging and managed with pain control.

Patients with fractures involving 3 or more ribs are generally recommended for hospital admission; such patients should be admitted. Also, elderly cases with 6 or more fractures should be admitted to the ICU [11].

Patients with osteoporosis should be treated accordingly. In all cases of cancer, these patients should be managed with referral to specialist. If child abuse is suspected, child protective services need to be consulted. In clinical practice depending upon condition, use of rib belt is prescribed; the device consist of a broad band with handles on either side to hold firm the belt. 

A rib fracture by itself is not a serious condition. The prognosis depends upon the seriousness of injury and involvement of one or more internal organs. The severity of the condition depends upon the type and numbers of ribs involved. Broken sharp ends of rib can rupture major blood vessels, puncture lungs or/and damage liver, kidney and/or spleen. As the number of fractures increase, so do the risk for mortality and pneumonia. Each rib fracture is associated with an additional 19% risk of fatality. Also each rib fracture increases the risk of contracting pneumonia by 27% [4].

Rib fracture is the commonest injury in cases of chest trauma caused to elderly patients. This population is associated with the highest mortality and morbidity rates following chest trauma. Furthermore, elderly patients who suffer rib fractures after blunt chest trauma, have double the risk of mortality and morbidity as compared to younger patients in the similar situation.

Further data shows that concurrent lower rib and pelvic fractures are associated with higher rates of organ damage [5]. In the elderly population, underlying cardiac and pulmonary disease increases the risk of morbidity and mortality [6].

A study conducted by a trauma service, which investigated the number of trauma patients with rib fractures, yielded a mortality rate of 12%. Furthermore, 32% developed hemothorax or pneumothorax and 94% developed associated injuries [7]. 

Rib fractures in athletes tend to affect the upper and middle ribs [8].

The etiology of fractured ribs is mainly due to trauma, pathological conditions, or bone-related diseases. In various age groups like children, adult and aged populations, the causes of rib fracture can vary:

• In children, child abuse and recreational sports are the most common causes.
• In adults, MVAs are the most frequent cause; the incidence increases in countries with higher numbers of MVAs.
• In the elderly, falls are the most common cause. 

Malignancies of various organs such as prostate, renal and breast metastasize to bone sites, which include the ribs. Primary bone tumors such as osteochondroma, osteosarcoma and others also invade the ribs. Rheumatoid arthritis is another pathological cause of rib fractures. A study carried out in Japanese patients suffering from rheumatoid arthritis, showed that 13.5% had incidental fracture. Out of which, the highest frequency of fracture sites in men were ribs [1].

Fragility fractures are seen in older populations suffering from osteoporosis, in which the bone mineral density becomes low. A significant portion of these fractures are ribs fracture. 

It is estimated that 10% of trauma patients will sustain rib fractures. Furthermore, rib fractures are found in 30% of patients with chest trauma. Fracture of first and second ribs is rare, the most affected ribs are 7th to10th ribs.

Children are the least susceptible group to develop rib fractures since their ribs are still elastic. In children, child abuse should be considered because of its high prevalence (83%) in children with rib fractures less than 2 years old.

The elderly population is the most susceptible group to complications from rib fractures. Rib fracture incidence in this group is associated with classical risk markers such as osteoporosis, old age, and history of fracture. Patients who have a history of rib fracture are more prone to subsequent rib fractures besides fracture of hip or wrist.

The role of the chest wall is to protect the organs situated within the chest. Hence the ribs, clavicles, sternum, and scapulae are structures which enable normal respiration.

Injury of chest wall can lead to compromised ventilation, secondary to:

• Inadequate pain control which hinders the breathing mechanism and can lead to atelectasis, inadequate oxygenation, and pneumonia.
• Numerous adjacent rib fractures that impede the mechanism of muscle coordination required for normal respiration.
• Fragments of the injured ribs can penetrate through organs such as the lungs resulting in hemothorax or pneumothorax.

The most common sites of fracture on a rib are the points of impact and the posterior location of the rib. The location indicates which associated complications may arise. The bottom two ribs can cause organ laceration to the spleen, liver, or kidney. Generally, the bottom two ribs do not fracture easily because they are not attached to the breastbone. Middle rib fractures cause pneumothorax due to the puncture of lung by the sharp broken edge.

Fractures of the upper first two ribs are not common, but if involved lead to serious consequences; the weakest point in the first rib is situated at the subclavian artery groove [2]. Fractures of the first rib occur when there is sudden impact causing the head and neck to thrust forward and thereby causing the scalene muscle to contract on the subclavian artery [3]. The possible injury to major blood vessels and brachial plexus of nerves leads to increased morbidity and mortality in these patients.

Prevention of rib fractures is very important. These are recommendations to high risk groups:

• In the athlete population, it is highly advised to wear protective equipment. 
• In the elderly population, special care and attention to decrease the risk by preventing falls is necessary. The home should include fall proof measures.
• In the group that is at risk for or affected with osteoporosis, it is essential to have sufficient calcium and vitamin D intake. Also, this population should have routine medical care. Those with osteoporosis should discuss with their clinician the drug therapies available. There are guidelines for surveillance and treatment for this group. 
• As said earlier in the treatment section, adequate pain control is essential to allow for normal breathing movements. If the patient is not breathing normally, there are issues such as atelectasis, hypoxia, pneumonia, etc. 
• All populations should wear seat belts when in a motor vehicle.  

Rib fractures are common injuries. There are numerous causes of rib fractures such as blunt chest trauma resulting from motor vehicle accidents (MVAs), falls, and contact sports. In addition, there are pathological causes such as malignancies, whether primary or metastatic lesions, that also cause rib fractures. Complications associated with rib fracture can be diverse and serious in nature:

• The clinical presentation and risks associated with the injury depend upon the number and location of ribs involved.
• One or more of the top three ribs broken can lead to sharp edges which can pierce major blood vessels and/or cause lung puncture leading to collapse of lungs. Broken lower ribs can damage internal organs like liver, spleen and kidneys.
• Critical care becomes necessary in situations leading to compromised ventilation, pneumothorax, pulmonary contusion and multiple organ injuries.  

Since rib fractures are associated with high risk of morbidity and increase in mortality, index of suspicion of a possible rib fracture should be greater when treating an individual following trauma. Rib fracture and other associated injuries can be ascertained through X-ray and other diagnostic tests. In general, simple injuries to ribs need no specific treatment and heal over a period of time. Complicated injuries involving other organs can be life threatening and may need more specialized critical care by hospitalization. Rib fracture associated with metabolic conditions like osteoporosis and cancer need specific treatment for these conditions.

A rib fracture can be very painful especially when you move, breathe or cough. It can take 1 to 2 months to heal. Discuss with your doctor on ways to treat your pain. Narcotics and NSAIDs (such as ibuprofen) can be used to help alleviate the pain. Other recommendations include using an ice pack to help with the pain and discomfort. Also, you should do slow deep breathing to help keep your lungs healthy. It is important to continue follow up with your doctor. If breathing is difficult and you develop anxiety, you should seek care immediately. 

Stay active because routine activities help increase the healing process. Always remember to wear your seatbelt while in a motor vehicle. Also wear protective gear when engaging in contact sports. Pay special attention to anything in your house that may contribute to falls. Prevention of fractures in general is very important and should be kept in mind.  

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2. Colosimo AJ, Byrne E, Heidt RS Jr, Carlonas RL, Wyatt H. Acute traumatic first-rib fracture in the contact athlete: a case report. American Journal of Sports Medicine. 2004; 32(5):1310-2.
3. Lee SJ, Chu SJ, Tsai SH. Isolated Bilateral First-rib Fractures. Journal of Emergency Medicine. 2008; 5:47-49.
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5. Al-Hassani A, Afifi I, Abdelrahman H, et al. Concurrent rib and pelvic fractures as an indicator of solid abdominal organ injury. International Journal of Surg. 2013; 11(6):483-6.
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7. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. The Journal of Trauma. 1994;37(6):975-9.
8. Coris EE, Higgins HW 2nd. First rib stress fractures in throwing athletes. American Journal of Sports Medicine. 2005; 33(9):1400-4.
9. Magu S, Yadav A, Agarwal S. Computed tomography in blunt chest trauma. The Indian Journal of Chest Diseases & Allied Science. 2009; 51(2):75-81.
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11. Easter A. Management of patients with multiple rib fractures. American Journal of Critical Care. 2001;10(5):320-7

• I fell and broke 8& 9th rib on right side a
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