Introduction

A rib fracture is a break in the bony segment of any rib and is most often the consequence of blunt trauma to the chest wall but can be due to underlying diseases which weaken the bone structure of the ribs. They can occur singly or in multiple places along the length of a rib and may be associated with soft tissue injuries to the surrounding muscles or the underlying lung.

Epidemiology

  • Incidence: 60.00 cases per 100,000 person-years
  • Peak incidence: 60-70 years
  • Sex ratio: 1:1
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Aetiology

Risk factors
  • most rib fractures are caused by blunt trauma to the chest wall
  • they are common in polytrauma with chest injuries being present in 25% of major trauma
  • spontaneous rib fractures can occur rarely following coughing or sneezing: usually there is a past medical history of osteoporosis, steroid use or chronic obstructive pulmonary disease
  • pathological rib fractures can also occur due to cancer metastases: the most common cancers which predispose to these are prostate in men and breast in women

Clinical features

Clinical features:
  • severe, sharp chest wall pain is the most common symptom; the pain is often more severe with deep breaths or coughing
  • there is usually significant chest wall tenderness over the site of the fractures and there may be visible bruising of the skin
  • auscultation of the chest may reveal crackles or reduced breath sounds if there is an underlying lung injury
  • pain and underlying lung injury can also result in a reduction in ventilation causing a drop in oxygen saturation
  • pneumothorax: this can be a serious complication of a rib fracture and presents with reduced chest expansion, reduced breath sounds and hyper-resonant percussion on the affected side

Flail chest:
  • this is a serious consequence of multiple rib fractures that can occur following trauma
  • it is caused by two or more rib fractures along three or more consecutive ribs, usually anteriorly
  • the flail segment moves paradoxically during respiration and impairs ventilation of the lung on the side of injury
  • the segment can cause serious contusional injury to the underlying lung if left untreated
  • often requires treatment with invasive ventilation and surgical fixation to prevent complications

Investigations

Investigations:
  • the best diagnostic test is a CT scan of the chest as this will show the fractures in 3D as well as the associated soft tissue injuries.
  • chest x-rays: while these sometimes demonstrate anterior or posterior fractures, they provide suboptimal views and do not provide any information about the surrounding soft tissue injury
  • in cases of pathological fractures secondary to tumour metastases, a CT scan to look for a primary (if not already identified) is also required

Management

Management:
  • the majority of cases are managed conservatively with good analgesia to ensure breathing is not affected by pain
    • inadequate ventilation may predispose to chest infections
  • surgical fixation can be considered to manage pain if this is still an issue and the fractures have failed to heal following 12 weeks of conservative management
  • flail chest segments are the only form of rib fractures which should be urgently discussed with cardiothoracic surgery as they can impair ventilation and result in significant lung trauma
  • lung complications such as pneumothorax or haemothorax should be managed as necessary