Rib fracture explained

Rib fracture
Synonyms:Broken rib, cracked rib
Field:Emergency medicine
Symptoms:Chest pain that is worse with breathing in
Complications:Pulmonary contusion, pneumothorax, pneumonia
Causes:Chest trauma
Diagnosis:Based on symptoms, medical imaging
Medication:Paracetamol (acetaminophen), NSAIDs, opioids
Prognosis:Pain improves over 6 weeks
Frequency:Common

A rib fracture is a break in a rib bone.[1] This typically results in chest pain that is worse with inspiration.[1] Bruising may occur at the site of the break.[2] When several ribs are broken in several places a flail chest results.[3] Potential complications include a pneumothorax, pulmonary contusion, and pneumonia.[4] [1]

Rib fractures usually occur from a direct blow to the chest such as during a motor vehicle collision or from a crush injury.[4] [1] Coughing or metastatic cancer may also result in a broken rib.[1] The middle ribs are most commonly fractured.[5] [1] Fractures of the first or second ribs are more likely to be associated with complications.[6] Diagnosis can be made based on symptoms and supported by medical imaging.[2]

Pain control is an important part of treatment.[7] This may include the use of paracetamol (acetaminophen), NSAIDs, or opioids.[4] A nerve block may be another option.[1] While fractured ribs can be wrapped, this may increase complications.[1] In those with a flail chest, surgery may improve outcomes.[8] [9] They are a common injury following trauma.[10]

Signs and symptoms

This typically results in chest pain that is worse with inspiration.[1] Bruising may occur at the site of the break.[2]

Complications

When several ribs are broken in several places a flail chest results.[3] Potential complications include a pneumothorax, pulmonary contusion, and pneumonia.[4] [1]

Causes

Rib fractures can occur with or without direct trauma during recreational activity. Cardiopulmonary resuscitation (CPR) has also been known to cause thoracic injury, including but not limited to rib and sternum fractures. They can also occur as a consequence of diseases such as cancer or rheumatoid arthritis. While for elderly individuals a fall can cause a rib fracture, in adults automobile accidents are a common event for such an injury.

Diagnosis

Signs of a broken rib may include:[11]

Plain X-rays often pick up displaced fractures but often miss undisplaced fractures.[12] CT scanning is generally able to pick up both types of fractures.[12]

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.[3] Rib fractures are also a sign of more serious injury in elderly people.[13]

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.[14] Flail chest is a potentially life-threatening injury and will often require a period of assisted ventilation.[15] 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., cervical spine injury). Spontaneous fractures in athletes generally require a cessation of the cause, e.g., time off rowing, while maintaining cardiovascular fitness.

Nerve blocks

Nerve blocks may be used to help with pain and reduce respiratory complications related to rib fractures.[16] These include rhomboid intercostal block,[17] epidural anesthesia, paravertebral block, erector spinae plane block and serratus anterior plane block.[18] [19] [20] There is very little evidence to support the use of one nerve block over another on the basis of analgesia or safety.[21] [22]

Surgery

Treatment options for internal fixation/repair of rib fractures include:

See also

Notes and References

  1. Book: Mosby's Medical Dictionary . E-Book. 2013. Elsevier Health Sciences. 978-0323112581. 1567. en. live. https://web.archive.org/web/20171013013051/https://books.google.ca/books?id=aW0zkZl0JgQC&pg=PA1567. 2017-10-13.
  2. Book: Adams. James G.. Emergency Medicine E-Book: Clinical Essentials (Expert Consult – Online). 2012. Elsevier Health Sciences. 978-1455733941. 682. en. live. https://web.archive.org/web/20171013013053/https://books.google.ca/books?id=rpoH-KYE93IC&pg=PA682. 2017-10-13.
  3. Wanek . Sandra . Mayberry . John C . Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury . Critical Care Clinics . 20 . 1 . 71–81 . 2004 . 14979330 . 10.1016/S0749-0704(03)00098-8 .
  4. May. L. Hillermann. C. Patil. S. Rib fracture management. BJA Education. January 2016. 16. 1. 26–32. 10.1093/bjaceaccp/mkv011. free.
  5. Book: Nanni, Christina. PET-CT: Rare Findings and Diseases. Springer. 2012. 978-3-642-24698-2. 257.
  6. Murphy CE. 4th. Raja. AS. Baumann. BM. Medak. AJ. Langdorf. MI. Nishijima. DK. Hendey. GW. Mower. WR. Rodriguez. RM. Rib Fracture Diagnosis in the Panscan Era.. Annals of Emergency Medicine. 27 May 2017. 10.1016/j.annemergmed.2017.04.011. 28559032. 70. 6. 904–909. 23442272.
  7. Brown. SD. Walters. MR. Patients with rib fractures: use of incentive spirometry volumes to guide care.. Journal of Trauma Nursing . 2012. 19. 2. 89–91; quiz 92–03. 10.1097/JTN.0b013e31825629ee. 22673074. 45547470.
  8. Schuurmans. J. Goslings. JC. Schepers. T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review.. European Journal of Trauma and Emergency Surgery. April 2017. 43. 2. 163–68. 10.1007/s00068-016-0721-2. 27572897. 5378742.
  9. Coughlin. TA. Ng. JW. Rollins. KE. Forward. DP. Ollivere. BJ. Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials.. The Bone & Joint Journal. August 2016. 98-B. 8. 1119–25. 10.1302/0301-620X.98B8.37282. 27482027.
  10. Senekjian. L. Nirula. R. Rib Fracture Fixation: Indications and Outcomes.. Critical Care Clinics. January 2017. 33. 1. 153–65. 10.1016/j.ccc.2016.08.009. 27894495.
  11. Web site: Broken or bruised ribs. 2015. 15 August 2015. NHS.UK. live. https://web.archive.org/web/20150820045022/http://www.nhs.uk/conditions/rib-injuries/Pages/Introduction.aspx. 20 August 2015.
  12. Dennis . BM . Bellister . SA . Guillamondegui . OD . Thoracic Trauma. . The Surgical Clinics of North America . October 2017 . 97 . 5 . 1047–1064 . 10.1016/j.suc.2017.06.009 . 28958357.
  13. Fatality Risk and the Presence of Rib Fractures. Annals of Advances in Automotive Medicine / Annual Scientific Conference. 2008-01-01. 1943-2461. 3256783. 19026224. 73–84. 52. Richard. Kent. William. Woods. Ola. Bostrom.
  14. Morice . A H . McGarvey . L . Pavord . I . Recommendations for the management of cough in adults . Thorax . 61 . Suppl 1 . i1–24 . 2006 . 16936230 . 2080754 . 10.1136/thx.2006.065144 .
  15. Book: Brunner & Suddarth's Textbook of Canadian Medical-surgical Nursing. Lippincott Williams & Wil. 637. 2009-01-01. 9780781799898. en. Pauline. Paul. Beverly. Williams. live. https://web.archive.org/web/20160629114720/https://books.google.com/books?id=SB_-CRXvZPYC&pg=PA637&lpg=PA637&dq=flail+chest+sometimes+needs+assisted+ventilation&source=bl&ots=LRmcVdhbz3&sig=KtI8XKo2R3QEdGiRIVK1ElqdaVw&hl=en&sa=X&ved=0CEQQ6AEwBmoVChMI84fwyaqrxwIVStKACh0AKwyV#v=onepage&q=flail%2520chest%2520sometimes%2520needs%2520assisted%2520ventilation&f=false. 2016-06-29.
  16. Mladenovic . Jordanna . Erskine . Ryan N. . Riley . Brooke . Mitchell . Andrew . Abi-fares . Catherine . Basson . Willem . Anstey . Chris . White . Leigh . 2022-11-01 . The association between erector spinae plane block timing and reduced rib fracture related respiratory complications: A cohort study . Journal of Clinical Anesthesia . en . 82 . 110940 . 10.1016/j.jclinane.2022.110940 . 35917775 . 251206240 . 0952-8180.
  17. Ökmen . K . Efficacy of rhomboid intercostal block for analgesia after thoracotomy. . The Korean Journal of Pain . 1 April 2019 . 32 . 2 . 129–132 . 10.3344/kjp.2019.32.2.129 . 31091512. 6549589 .
  18. Wardhan . R . Assessment and management of rib fracture pain in geriatric population: an ode to old age. . Current Opinion in Anesthesiology . October 2013 . 26 . 5 . 626–31 . 10.1097/01.aco.0000432516.93715.a7 . 23995061. 35082310 .
  19. Book: Grant . Stuart A. . Auyong . David B. . Ultrasound Guided Regional Anesthesia . 2016 . Oxford University Press . 9780190630478 . PT388 . en.
  20. Riley. B.. Malla. U.. Snels. N.. Mitchell. A.. Abi-Fares. C.. Basson. W.. Anstey. C.. White. L.. 2020. Erector spinae and serratus anterior blocks for the management of rib fractures: A retrospective exploratory matched study. The American Journal of Emergency Medicine. 38. 8. en. 1689–1691. 10.1016/j.ajem.2020.01.007. 31932127. 210194417.
  21. White. L.. Riley. B.. Malla. U.. Snels. N.. Mitchell. A.. Abi-Fares. C.. Basson. W.. Anstey. C.. 2020-08-15. ESB vs SAB in chest wall trauma, which is better?: A response and decision making guide. The American Journal of Emergency Medicine. 38. en. 10. 2221–2223. 10.1016/j.ajem.2020.08.004. 32843243. 221328812. 0735-6757.
  22. White . L. D. . Riley . B. . Davis . K. . Thang . C. . Mitchell . A. . Abi-fares . C. . Basson . W. . Anstey . C. . Safety of Continuous Erector Spinae Catheters in Chest Trauma: A Retrospective Cohort Study . Anesthesia & Analgesia . 2021 . 133 . 5 . 1296–1302 . 10.1213/ANE.0000000000005730 . 34473654 . 0003-2999. 10072/407871 . 237400070 . free .
  23. Fitzpatrick . D. C. . Denard . P. J. . Phelan . D. . Long . W. B. . Madey . S. M. . Bottlang . M. . Operative stabilization of flail chest injuries: review of literature and fixation options . European Journal of Trauma and Emergency Surgery . 36 . 5 . 427–33 . 2010 . 21841954 . 3150812 . 10.1007/s00068-010-0027-8 .
  24. Book: Mathison. Douglas. Master Techniques in Surgery: Thoracic Surgery: Transplantation, Tracheal Resections, Mediastinal Tumors, Extended Thoracic Resections. 2014. Walters-Kluwer Health. 978-1-46988-903-0. 15 August 2015. live. https://web.archive.org/web/20160512081713/https://books.google.com/books?id=2u8NBQAAQBAJ&pg=PT338&dq=Synthes+MatrixRIB+Fixation+System&hl=en&sa=X&ved=0CB4Q6AEwAGoVChMIgZ_dpZ2rxwIVypWACh3JUwpm#v=onepage&q=Synthes%20MatrixRIB%20Fixation%20System&f=false. 12 May 2016.
  25. Book: Browner, Bruce D.. Skeletal Trauma: Basic Science, Management, and Reconstruction. Elsevier Health Scien. 1418. 2009-01-01. 978-1416022206. en. live. https://web.archive.org/web/20160508172225/https://books.google.com/books?id=IDXgoS0vLFQC&pg=PA1418&dq=anterior+locking+plate&hl=en&sa=X&ved=0CD4Q6AEwBmoVChMIzNqshZyrxwIVy9SACh1ozgL0#v=onepage&q=anterior%2520locking%2520plate&f=false. 2016-05-08.
  26. de Jong . M. B. . Kokke . M. C. . Hietbrink . F. . Leenen . L. P. H. . Surgical Management of Rib Fractures: Strategies and Literature Review . Scandinavian Journal of Surgery . 103 . 2 . 120–25 . 2014 . 24782038 . 10.1177/1457496914531928 . 11113635 . free .

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