Rib fractures are common injuries, occurring in approximately 10% of trauma patients. They may occur anywhere along the bone, however are most frequently seen along the posteriolateral bend where the rib is the weakest.
Structure and function
The thoracic wall is made up of twelve pairs ribs which act to protect the organs of the thoracic and abdominal cavities, including the heart, lungs, liver, spleen, and kidneys. The ribs also act as sites of attachment of muscles necessary for respiration and movements of the neck, upper limbs, and torso. (INSERT THORACIC CAVITY PHOTO HERE)
The twelve ribs are curved flat bones that attach to thoracic vertebral at their head and extend anteriorly by their shaft. Rib pairs one through seven are termed “true ribs” (vertebrocostal) as they attach to the sternum through their own costal cartilage. “False” (certebrochondral) ribs (rib pairs 8 through 10) attach indirectly to the sternum via the costal cartilage of the seventh rib. The eleventh and twelfth rib pairs are “floating” (vertebral, free) ribs that do not connect to the sternum and instead have cartilage “caps” that end in the abdominal musculature. The cartilage component of the thoracic wall increases the compressive strength of the ribs and significantly decreases the risk of fracture secondary to direct blow or compression. There is some variability in rib anatomy, with “supernumerary” ribs are most common in the cervical and lumbar regions. Additional cervical ribs may result in thoracic outlet syndrome. (LINK?)
The first rib is short and broad and is not palpable making it rarely fractures due to its protected position inferior to the clavicle. Fractures to the first three ribs may result in injury to the brachial plexus, subclavian vessels and mediastinum. The middle ribs are the most commonly fractured, typically secondary to direct blow or crushing injury. Lower rib fractures (9-12) post a significant risk to internal organs including lung, diaphragm, liver and spleen.
Rib fractures can occur after motor vehicle accidents (MVA), blunt trauma, metabolic disease or secondary to repeated stress. Athletes and elderly individuals are more likely to present with rib fractures.
Rib fractures can occur secondary to high-energy stresses or low-energy stresses depending on the patient’s age, pre-existing medical conditions, and mechanism of injury. High-energy trauma can include blunt trauma, MVA, penetrating trauma, and crush injury. Low-energy stresses include coughing and sneezing. Rib fractures can also occur secondary to repeated stress as a result of increased physical activity and/or poor biomehcanics. Pathologic rib fractures are caused by weakening of the bone secondary to osteoporosis or metastatic disease. The most common primary sites include the breast, prostate and kidney.
Patients may present with pain which increases upon inspiration. Pain can be provoked by deep breathing, coughing, laughing, and sneezing.On examination there may be deformity, swelling, ecchymosis and decreased thoracic excursion. Bony crepitus may be heard on auscultation of the fracture site. There is likely to be palpable tenderness, and a step-off or other deformity may be palpable at the site of injury.
Flail chest occurs when three or more ribs are fractures in two or more places, resulting in a free segment which can move paradoxically with respiration (i.e. in with inspiration and out with expiration). It is a condition that is important not to miss as it may significantly compromise a patient's ability to breathe, and has been shown to increase rates of morbidity and mortality. Reductions in blood pressure should prompt In the paediatric population, rib fractures should raise awareness of the possibility of abuse as ribs in children are much more flexible than in adults, with much greater forces required to cause fracture.
Associated injuries include pneumothorax, hepatic or splenic laceration, atelectasis, and pneumonia.
Initial imaging for rib fractures should include postero-anterior (PA) and lateral chest x-rays. If unable to obtain PA secondary to patient hemodynamic instability or mobility, AP films may be obtained. It is important to look at each rib individually for continuity of bone. Fractures are often seen at the site of impact or along the posterolateral bend where the rib is the weakest. However, x-rays may not reveal an undisplaced rib fracture for 10-14 days after injury. It is important to inspect the mediastinum on the PA chest x-rays to rule out any vascular injury (e.g. aorta) which is more common in fractures of the first three ribs. It is also crucial to look for signs of pneumothorax or hemothorax. (LINK?) It is often recommended to do repeat chest x-rays in 6 hours to rule out delayed pneumothorax or hemothorax.
It is possible to obtain specific rib series x-rays, however these are not ordered regularly as PA and lateral views typically suffice. Rib series imaging may be obtained only if fractures are not visible on the other views and there is a high clinical suspicion and the diagnosis would alter the patient's management.
CT imaging may be ordered to evaluate trauma patients and to rule out suspected intra-abdominal injury.
Bone scan has been shown to be better than MRI in diagnosing stress fractures early on, especially for athletes for return to competition.
RIB FRACTURE XR IMAGE FROM WIKIPEDIA http://en.wikipedia.org/wiki/File: PfracturedribX.png) - image like this
RIB FRACTURE CT IMAGE FROM WIKIPEIA http://en.wikipedia.org/wiki/File: PfracturedribCT.png - image like this
Risk factors and prevention
Injury rates may be reduced with improvement in biomechanics, appropriate management of osteoporosis in elderly and protection in or avoidance of activities that could result in direct blow or crushing injury.
Appropriate analgesia is very important in all patients who have sustained rib fracture independent of the cause of injury. With poor pain management patients are at risk of developing atelectasis and/or pneumonia due to decreased respiratory frequency, tidal volume, and coughing. Initiating respiratory hygiene measures may be appropriate depending on the patient and degree of injury.
Pharmacotherapy options include non-steroidal anti-inflammatories, narcotics, intercostal nerve blocks.
Surgical management is reserved for patients with flail chest or non-union. Flail chest is managed surgically through the placement of hooks or wires to stop the segment from moving independently. Other surgical modalities include malleable plates over the anterior surface of the rib, wire cerclage, rib plate, u-plates and screws.
Stress fractures may be managed by restricting activity for 4-6 weeks and gradual return to activities with emphasis on proper biomechanics.
Admitted patients whould be monitored for pain, oxygenation, DVT prophylaxis, abx if chest tube is inserted. Pain management can be achieved through continuous epidural infusion, which has been associated with decreased need for mechanical ventilation and decreased incidence of pneumonia.
Return to work and physical activity timelines are patient specific and depend on the intensity of activity desired and the degree of initial injury. Heavy labourers may be restricted from activity for a minimum of 3 weeks. Patients involved in contact sports may return to activity within 1 week or injury if the rib is protected with a flak jacket or other device, which must be worn for 6-8 weeks.
Stress injuries require 4-6 weeks before return with appropriate rehabilitation and biomechanical training.
Non-union occurs when bone ends fail to grow together which may result months to year after the time of injury. In these cases the patient may continue to complain of pain. These patients may need to be managed surgically with a plate to stabilize.
Pneumonia is the most common complication of rib fracture, affecting 6-34% of all patients in hospital with rib fracture.
Appropriate management of osteoporosis is crucial in preventing rib fractures in elderly patients. Appropriate alterations in diet and/or supplementation with vitamin D, calcium, and ensuring proprer protein intake...
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Rib fracture, thoracic wall, chest wall, stress fracture.
1. History taking
2. Physical Exam - Cardiovascular and Respiratory