2.  46 YOM with no reported
chronic medical problems
presents after mechanical
fall onto his right side. He
is complaining of right
sided flank/chest pain with
deep inspiration. At
presentation he is
awake/alert in no
respiratory distress. He has
been otherwise well free of
other injury or illness.
 T 98.9 P 90 BP 148/76
O2 99% RR 16
 Gen: WDWN
 CV: RRR, no m/r/g
 Pulm: Lungs CTA bilat,
BBSE, on examination
of the chest wall the
patient is tender to
palpation over soft
tissue swelling and
ecchymosis in the right
lower chest wall in the
 Abd: s/nt/nd

4. PA lateral film of right ninth rib
fracture. No PTX was present
CT from the same patient in the PA and
lateral films above. This clearly shows the
rib displacement near the liver on the right

5.  Oxygen
 IV Fluids
 Adequate analgesia (with NSAIDs and opioid analgesics) and pulmonary toilet
are the mainstays of treatment
 Consider intercostal nerve blocks for more adequate pain control
 Inpatient criteria:
 are elderly
 have preexisting pulmonary disease or significant comorbidities that would
impair healing in an outpatient setting.
 Flail chest injuries
 As above including strong consideration of ventilatory support if:
 3 or more associated injuries
 severe head trauma
 comorbid pulmonary disease
 age > 65 yrs.
 fracture of 8 or more ribs

6.  Diagnosis
 Rib fractures have the appearance of an abrupt discontinuity in the
smooth outline of the rib. A lucent fracture line may be seen.
 A common pattern for evaluating the ribs is to examine the posterior
portions of the ribs first, then the anterior portions, and finish by
examining the lateral aspects of each rib. If you see an abnormality,
follow that rib in its entirety.
 If it is necessary to exclude a rib fracture, oblique rib detail films should
be obtained.
 Up to 50 percent of rib fractures (especially those involving the anterior
and lateral portions of the first five ribs) may not be apparent on x-ray.
 A rib fracture is a CLINICAL diagnosis
 Oblique films can be obtained to better define area of concern.
 The principal diagnostic goal with clinically suspected rib fractures is
the detection of significant complications: pneuomothorax,
hemopneumothorax, pulmonary contusion, major vascular injury, etc..
 Most common location of rib fracture is posterior in nature

7.  Significance of rib fracture
 The pain of rib fractures can greatly interfere with ventilation.
 Admit patients with fractured ribs for at least 24 to 48 h if they cannot
cough and clear their secretions adequately, especially if they are elderly or
have preexisting pulmonary disease.
 Fracture of the upper three ribs is associated with an increased risk of
significant injury (often vascular) because of the excessive force needed to
fracture these ribs.
 Fracture of the lower three ribs can be associated with liver or spleen injury
 Rib fractures in children should raise suspicion for child abuse given the
compliance of the pediatric rib and the force needed to fracture one.

8. Left 7th posterior rib fracture in
a pediatric patient
Right first rib fracture

9. Flail Chest. Radiograph at left and CT at right demonstrate multiple rib
fractures (white arrows) with some ribs fractured in two or more places (see CT
scan). There is also a pulmonary contusion (red arrow), subcutaneous
emphysema (yellow arrows) and a fracture of the left transverse process of the
vertebral body imaged on the CT scan