Rib fractures are commonly caused by blunt chest trauma and are often seen following motor vehicle crashes and falls. While usually not life-threatening on their own, they can indicate more severe underlying injuries to the chest or abdomen. Treatment focuses on pain management to prevent respiratory complications and complications are more common in elderly patients and those with multiple rib fractures.

1. Rib Fractures
Dr. D. N. Bid

2. Background
• Simple rib #s are the most common injury
sustained following blunt chest trauma.
• Approximately 10% of all patients admitted after
blunt chest trauma have one or more rib #s.
• These #s are rarely life-threatening in themselves
but can be an external marker of more severe
visceral injury inside the abdomen and the chest.

3. • The most common mechanism of injury for rib #s
in elderly persons is a fall from height or from
standing.
• In adults, MVA is the most common mechanism.
• Youths sustain rib #s most often secondary to
recreational and athletic activities, as well as by
non-accidental trauma.

4. • Rib #s may also be pathologic. Cancers that
metastasize to bone (eg, prostate, breast,
renal) frequently become apparent in a rib.
• Ribs are relatively thin compared with major
long bones and are more likely to # when
invaded by a metastatic lesion.

5. • The chest wall protects underlying sensitive
structures by surrounding internal organs with
hard osseous structures including the ribs,
clavicles, sternum, and scapulae.
• An intact chest wall is necessary for normal
respiration.

6. • Rib #s may compromise ventilation by a variety of
mechanisms. Pain from rib #s can cause respiratory
splinting, resulting in atelectasis and pneumonia.
• Multiple contiguous rib #s (i.e., flail chest) interfere
with normal costovertebral and diaphragmatic
muscle excursion, potentially causing ventilatory
insufficiency.

7. • Fragments of #ed ribs can also act as
penetrating objects leading to the formation
of a hemothorax or a pneumothorax.
• Ribs commonly # at the point of impact or at
the posterior angle (structurally their weakest
area). Ribs four through nine (4-9) are the
most commonly injured.

8. • The thinnest and weakest portion of the first
rib is at the groove for the subclavian artery.
• The mechanism of first-rib injury in MVAs
seems to be a violent contraction of the
scalene muscles brought on by the sudden
forward movement of the head and neck.

9. • A single blow may cause rib #s in multiple
places.
• Traumatic #s most often occur at the site of
impact or the posterolateral bend, where the
rib is weakest.
• Due to the greater pliability of children's ribs,
greater force is required to produce a #.

10. Mortality/Morbidity
• Rib #s are not usually
dangerous in and of
themselves.
• Patients may develop
pneumonia from
splinting.
• Morbidity correlates
with the degree of
injury to underlying
structures.

11. Age
• Because children have more elastic ribs, they
are less likely than adults to sustain #s
following blunt chest trauma.
• Elderly individuals are more likely to have
associated injuries and complications.

12. Clinical Presentation
• Description of the prehospital scene by
paramedics can provide important clues to the
possibility of rib #s.
• After MVA, deformation of the steering wheel
and activation of seat belts and airbags have
been associated with rib injuries.
• Patients with rib # frequently complain of pain
on inspiration and dyspnea.

13. • Rib #s have been reported after coughing
spells without other significant trauma.
• Athletes with high force, recurrent
movements of the arms (e.g., discus throwers)
have had stress #s of the upper and middle
ribs.

14. • Tenderness on palpation, crepitus, and chest
wall deformity are common findings of rib #.
• Paradoxical chest wall excursion with
inspiration is seen with flail chest.

15. • A flail chest occurs when a large segment of ribs
is not attached to the spine.
• These ribs are broken in at least 2 places on each
rib.
• The paradoxical movement occurs because the
middle section of the rib between the 2 # sites
moves in response to intrathoracic pressure
changes not intercostal muscle contractions.

16. • Specific signs of ventilatory insufficiency
include cyanosis, tachypnea, retractions, and
use of accessory muscles for ventilation.
• Less specific signs include anxiety and
agitation.

17. • Bruising near # site is uncommon in pediatric
rib #s.
• If # of the lower ribs is suspected, assess the
patient for abdominal tenderness and costal
margin tenderness, which could raise
suspicion for injury to intra-abdominal organs.

18. Causes
• Blunt trauma including
motor vehicle crashes,
assault, falls, especially
down staircases.
• Coughing spells
• Non-accidental trauma in
pediatric cases
• Repetitive minor trauma
• Stress #s to the first rib in
throwing athletes

19. Chest radiographs
• AP and lateral chest films are used routinely to
assist in the diagnosis of rib #s.
• Chest radiographs are much more useful in the
diagnosis of underlying injuries, including
hemothorax, pneumothorax, lung contusion,
atelectasis, pneumonia, and vascular injuries.
• Findings of sternal # or scapular # should
increase suspicion for rib #s.

20. Prehospital Care
• Prehospital care should
focus on airway
maintenance and
supplemental oxygen.

21. Emergency care
• Goal of initial ED care is stabilization of the
trauma patient and multisystem trauma
evaluation.
• Respiratory care, including use of incentive
spirometry to prevent atelectasis and its
complications, is often important.
• Holding a pillow or similar soft brace against the
# site reduces discomfort while using the
spirometer or when coughing.

22. • Pain control is fundamental to the management
of rib #s to decrease chest wall splinting and
alveolar collapse in order to clear pulmonary
secretions.
• Isolated rib #s, without associated injuries, may
be managed on an outpatient basis with oral
analgesics, starting with NSAIDs if not
contraindicated and progressing to narcotics if
not sufficient.

23. • While rib belts or binders
do control pain, they have
been linked to
hypoventilation,
atelectasis, and
pneumonia.
• As a result, their use is no
longer recommended.

24. • For patients with a
significant mechanism of
trauma, a CT of the chest
and abdomen can be
useful in scanning for
significant related injury.
• It is recommended that
hospital admission for any
patient with 3 or more rib
#s, and ICU care for
elderly patients with 6 or
more rib #s.

25. Further Outpatient Care
• Patients with minor rib injuries able to cough and
clear secretions may be discharged with
adequate analgesic medications.
• Adequate analgesics are critical to successful
outpatient management of rib #s.
• Most patients who will develop complications will
do so within 2 weeks, so a follow-up plan within 2
weeks should be made.

26. • Consider an incentive spirometer, especially
with multiple #s, as it may help avoid
complications and remind the patient to avoid
splinting and to take deep breaths.

27. Further Inpatient Care
• Patients with isolated rib #s who are unable to cough
and clear secretions adequately should be considered
for admission for 24-hour observation.
• Consider admission for patients with underlying lung
disease or decreased pulmonary reserve.
• A lower threshold for admission of older persons with
isolated rib #s is warranted because of their higher
incidence of hypoventilation, hypercapnia, atelectasis,
and pneumonia.

28. Prognosis
• Isolated rib #s in
younger patients have a
good prognosis.
• Older patients have a
higher incidence of
significant pulmonary
complications.

29. Patient Education
• Return to work or sport depends on the activity
involved and the level of pain.
• Heavy labor and intensive training for athletes with
stress #s are not recommended for the first 3 weeks.
• When pain is not present at rest, the patient can begin
to increase his or her activity level but this should be
gradually done.
• Most rib #s heal within 6 weeks.

30. • Virtually all nonpathologic rib #s heal well
with conservative management.
• Some patients are able to return to work
within a few days, depending on their
occupation.

31. Thank you..

32. Fracture of the sternum
• Fracture of the sternum can be caused either by direct
trauma, which requires extreme force and is usually
associated with other injuries, or by violent flexion of the
thoracic spine accompanied by a wedge fracture of the
thoracic spine.
• Fractures of the sternum are not serious in themselves and
usually unite soundly, but their presence should alert the
doctor to the possibility of a more serious injury. A flail
segment including the mediastinum may be difficult to
control, even by positive pressure respiration (see Fig. 11.3).

33. • Treatment
If the fractured sternum is not properly
aligned it may need reduction and wiring.