Rib fracture

A rib fracture is a break or fracture in one or more of the bones making up the rib cage.

The first rib is rarely fractured because of its protected position behind the clavicle (collarbone). However, if it is broken serious damage can occur to the brachial plexus of nerves and the subclavian vessels. Fractures of the first and second ribs may be more likely to be associated with head and facial injuries than other rib fractures.

The middle ribs are the ones most commonly fractured. Fractures usually occur from direct blows or from indirect crushing injuries. The weakest part of a rib is just anterior to its angle, but a fracture can occur anywhere. The most commonly fractured ribs are the 7th and 10th.

A lower rib fracture has the complication of potentially injuring the diaphragm, which could result in a diaphragmatic hernia.

Rib fractures are usually quite painful because the ribs have to move to allow for breathing. Even a small crack can inflame a tendon and cripple an arm.

When several ribs are broken in several places a flail chest results, and the detached bone sections will move separately from the rest of the chest.

Causes

Rib fractures can occur without direct trauma and have been reported after sustained coughing and in various sports – for example, rowing and golf – often in elite athletes. They can also occur as a consequence of diseases such as cancer or infections (pathological fracture).

Fragility fractures of ribs can occur due to diseased bone structure, e.g., osteoporosis and metastatic deposits.

Diagnosis

Broken ribs are often indicated by the following symptoms:

• Pain when breathing or with movement
• A portion of the chest wall moving separately from the rest of the chest (flail chest)
• A grating sound with breathing or movement
• Where the mechanism of injury would indicate substantial force to the ribs

Because children have more flexible chest walls than adults do, their ribs are more likely to bend than to break; therefore the presence of rib fractures in children is evidence of a significant amount of force and may indicate severe thoracic injuries such as pulmonary contusion. Rib fractures are also a sign of more serious injury in elderly people.

Frontal radiograph of the chest demonstrates multiple rib fractures with callous formation, including a fracture of the left 2nd and 6th ribs posteriorly. Posterior rib fractures are highly suggestive of child abuse (from forceful squeezing)

Treatment

There is no specific treatment for rib fractures, but various supportive measures can be taken. In simple rib fractures, pain can lead to reduced movement and cough suppression; this can contribute to formation of secondary chest infection. Adequate analgesia can avoid this.

Flail chest is a potentially life-threatening injury and will often require a period of assisted ventilation. Flail chest and first rib fractures are high-energy injuries and should prompt investigation of damage to underlying viscera (e.g., lung contusion) or remotely (e.g., C spine injury).

Spontaneous fractures in sports people generally require a cessation of the cause, e.g., time off rowing, whilst maintaining cardiovascular fitness.