Rib Fracture

Original Editor - Lucinda hampton Top Contributors - Lucinda hampton and Kim Jackson

Introduction

Multiple old fractured ribs L side marked.

Rib fractures occur when a significant enough force directed at the rib causes a break. Rib fractures are often associated with other injuries and the greater the number of rib fractures the more likely are associated injuries Rib fractures can occur at any age, but older people are at higher risk because of osteoporosis

Rib fractures are most often treated with pain management and breathing exercises to prevent complication and additional damage to lungs.

For Clinically Relevant Anatomy see Ribs

Pathology

Rib cage

Fractures of the:

• 4th-10th ribs are the most common
• 1st-3rd ribs are associated with high-energy trauma

When the rib is fractured:

• Twice, the term floating rib is used to describe the free fracture fragment
• Thrice or more, contiguous floating ribs are present this is called a flail chest.

Etiology

Include:

• Blunt and penetrating trauma: e.g. motor vehicle accidents, falls, assaults - most common injury is blunt thoracic trauma, occurring in 50% of cases
• Pathological fractures eg Osteoporosis, malignancies.
• Stress fractures: occur more commonly in high-level athletes eg rowers, see image R
• Child abuse
• Cardiopulmonary resuscitation (CPR): occurs in 1 in 3 5
• Fetal rib fractures: caused by skeletal dysplasias
• Radiation-induced rib fractures 8-9
• Spontaneous rib fracture

Clinical Presentation

The most common symptom of rib fractures is pain with touch, taking a deep breath, sneezing, or coughing. As these fractures are quite painful, patients take short shallow breaths, and minimize movement. This can lead to collapse of the alveoli in the lungs, which makes breathing even harder and can subsequently lead to pneumonia.

Possible presenting symptoms:

• Ache in the ribs that is particularly prominent at night or first thing in the morning (particularly the first few days following injury).
• Pain may increase when lying on the affected side, applying pressure to the rib region or on firmly touching the rib at the site of injury.
• Pain during movements of the upper back such as bending or twisting, or sometimes during certain activities of the upper limb (such as overhead activities, or during heavy pushing, pulling or lifting).

Diagnostic Procedures

A thorough subjective and objective examination from a physiotherapist is important to assist with diagnosis of a fractured rib

However to determine the likelihood of associated damage to other organs such as the lungs (e.g. a pneumothorax), liver, spleen or kidneys. Investigations such as an X-ray, MRI or CT scan may be performed to confirm diagnosis.

1. Plain radiograph - may miss up to 50% of rib fractures even with dedicated oblique rib projections
2. CT - more sensitive than plain radiography for the detection of rib fractures
3. Ultrasound - more sensitive and specific than conventional radiography for rib fracture detection in blunt trauma when performed by a trained clinician

Outcome Measures

Modified BORG Scale

VAS Scale for Pain

Management / Interventions

Rib fractures themselves are treated symptomatically and have a good prognostic outcome.

• For simple, isolated rib fractures, conservative therapy is usually adequate which includes appropriate analgesia, rest, and ice. The use of an incentive spirometer should be encouraged to prevent pulmonary atelectasis and splinting. Intercostal nerve blocks can also be applied to aid in pain control. Rib taping is no longer the recommended treatment as it can impede inspiratory effort.

• If the broken ribs are bent or displaced in such a way that they puncture the lungs, surgery might be needed to put the ribs back together using thin steel plates (called rib plating). Similarly, flail chest may require surgical rib fixation.
• Rib fractures can take up to 3 months to fully heal.

Treatment of rib fractures is considered completed when a patient can take deep breaths, cough effectively, and walk without significant discomfort.

Associations

Rib fractures are often associated with other injuries and the greater the number of rib fractures the more likely are associated injuries:

• brachial plexus or subclavian vessel injuries (1st-3rd rib fractures)
• pneumothorax/haemothorax
• pulmonary laceration
• lung herniation
• liver, kidney and spleen traumatic injuries (10th-12th rib fractures)

Aside from immediate traumatic complications outlined above atelectasis and pneumonia may develop, mainly due to poor respiratory effort secondary to pain, and this increases the morbidity and mortality due to rib fractures

Physiotherapy

Physiotherapy treatment can assist patients with this condition and ensure they have a safe return to activity. Treatment may comprise:

• education
• rest from aggravating activities
• dry needling
• protective padding
• exercises to improve posture, flexibility and strength, and to prevent localized lung collapse
• activity modification advice
• taping techniques (e.g. postural taping)
• a graduated return to activity plan
• soft tissue massage
• joint mobilization (usually following completion of fracture healing)
• electrotherapy
• home exercise plan eg postural exercises, deep breathing exercises, thoracic rotation exercises.