Fracture, Rib

By admin On Sep 19, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Fracture, Rib

Robert J. Baker

Basics

Description

May be the result of acute chest trauma, especially in contact sports
Stress fractures can occur as a result of chronic overuse of the upper body (1,2,3,4)[B].
Fractures may be complete, incomplete, or stress-related (1)[C].
Rib fractures may often be associated with other fractures, soft tissue injuries, and deep organ trauma (5)[C].
Synonym(s): Broken ribs; Double fractures of the chest: Steering wheel injury, flail chest, stove-in chest (6)[C]

Epidemiology

Isolated fractures of the upper 4 ribs are rare because they are well protected by the shoulder complex (1,6,7)[B].
When injury occurs, trauma can be significant enough to fracture other bones of the shoulder, and injury to the deep organs such as lungs, heart, bronchus, blood vessels, and/or esophagus must be considered (5)[C].
Blunt trauma to the lower 8 ribs commonly results in fractures, most commonly related to blunt trauma of contact sports, such as football, hockey, and rugby (6,8)[C].
Forceful contraction, usually against a significant amount of resistance, of muscles with an attachment to the ribs may result in incomplete, complete, or avulsion fractures of the ribs (2,3)[B].
Chronic stress of upper body muscles, which attach to the ribs, can result in stress fractures of the ribs. Commonly seen in rowing, tennis, golf, gymnastics, and baseball (2,3,9)[B].
1st rib fractures have been reported as a result of falling on an outstretched arm, as well as direct trauma. 1st rib stress fractures also reported in the literature (1,7,8,10)[B].
Avulsion fractures of the lower 3 floating ribs often occur at the attachment of the external oblique muscles. Known to occur in baseball pitchers and batters (4,11,12)[B].
Multiple rib fractures occur in high-impact trauma such as automobile, motorcycle, mountain biking, and bicycle racing (6)[B].
Rib fractures more common in adults compared to children due to the relative inelasticity of the adult chest wall compared to children (6,13)[C].

Risk Factors

Rib fractures most likely occur in contact and collision sports such as football, hockey, boxing, wrestling, rugby, and soccer (1)[A].
As with any trauma, injuries can be more severe in athletes unprepared, either from lack of conditioning or contact from the back or blind side.
Stress fractures of the ribs more likely occur in sports with increased upper body demands such as golf, rowing, gymnastics, baseball, tennis, racquet sports, and weight-lifting. Overuse and poor technique can contribute to rib stress fractures (2,3,7)[B].
Other predisposing factors include a history of bone or joint disease, bone tumors, metastatic cancer, poor nutrition, and calcium deficiency (6,7)[C].

Genetics

There is no known genetic link for rib fractures. Those pathological fractures can occur in association with other bone tumors and metastatic cancer.

General Prevention

Protective equipment for contact sports is available for high-risk athletes. Rib protectors are available in football. Flack jackets are available for use in other contact sports.
Appropriate conditioning and technique in upper extremity sports is recommended for prevention of stress fractures (2,3,13)[C].

Etiology

Most acute rib fractures occur as a result of direct trauma, either blunt or penetrating missile (ie, ball, gunshot) (6)[C].
Relative long, thin shape of the rib predisposes to fractures. Common specific location is posterior lateral bend (6)[C].
Because of the rib's thin bony structure compared to other long bones, fracture may occur earlier due to pathological causes (13)[C].
Because there are multiple muscle attachments of the rib to the neck and upper extremities, stress can lead to fatigue fractures of the ribs (1,2,3,13)[B].

Commonly Associated Conditions

Organ injuries that may occur with acute rib fractures include:

Pulmonary contusion
Pneumothorax
Tension pneumothorax
Hemothorax
Liver laceration, especially with lower rib fractures
Spleen laceration, especially with lower rib fractures
Esophageal rupture
Great vessel injury, aorta and superior vena cava with upper and middle rib fractures (5)[C]

Diagnosis

Pre Hospital

Prehospital care is directed at stabilizing the athlete.
Evaluate and treat for shock in penetrating wounds, open fractures, and suspected internal injuries where blood loss is likely.
Evaluate and treat for respiratory distress where tension pneumothorax, unstable multiple rib fractures, or flail chest is present (5)[A].
In the case of tension pneumothorax, diagnosis and aspiration may be life-saving prior to transfer (5)[C].

History

Acute rib fracture usually presents after chest trauma. Can result from a fall on an outstretched arm.
Athletes may experience the sensation of having the “the wind knocked out of them.”
Athlete may recall feeling a “pop” when the trauma occurred.
Athlete may complain of abdominal pain if the lower (11th and 12th) ribs are involved.
Stress fractures usually occur in elite athletes who train intensely. These fractures tend to be more gradual in onset (7)[C].

Physical Exam

Localized pain over the involved rib(s)
Sensation of crepitus over the fracture site(s)
Pain generally exacerbated by deep inspiration, resulting in shallow, rapid breathing
Pain aggravated by coughing and sneezing
Other symptoms, such as increasing shortness of breath, increasing pain, cyanosis, and SC emphysema, may indicate serious life-threatening conditions requiring emergent attention.
Palpable deformity may be present in complete displaced fracture.
Swelling and ecchymosis may be present in the area of rib fractures.
In athletes involved in sports with heavy upper extremity activity, stress fractures may present as gradual-onset localized rib pain, with or without deformity. Pain may radiate backward (2,3,8)[B].
Localized rib tenderness is the cardinal finding.
Obvious deformity or crepitation at the fracture site may be present.
Palpable swelling, with or without ecchymosis, may be present at the fracture site.
SC emphysema may be present, especially with associated pneumothorax.
With significant chest trauma, a thorough cardiopulmonary examination must be performed to rule out complications or associated injuries (14)[B].
If trauma occurred to the upper chest, special attention should be given to the neck, shoulders, and major vessels (5,14)[B].
If trauma occurred to the lower chest, a thorough abdominal examination should be performed to rule out injury to the liver, spleen, GI tract, and kidneys (6)[C].

Diagnostic Tests & Interpretation

Lab

In the case of pathologic fractures, other blood work, such as CBC, comprehensive metabolic panel, and isoenzymes of alkaline phosphatase may be directed by history and physical (15)[B].
Appropriate blood work directed at associated injury of internal organs may be indicated; however, no direct blood work is necessary to diagnose the rib fracture.

Imaging

Most rib fractures heal without need for reduction or immobilization; thus, postreduction films are not required (6)[C].
Healing 1st rib fractures may compromise the vasculature to the upper extremity (8,10)[B].
Repeat films may be performed to monitor this complication during healing ()[B].
Other than in cases of complications, continued pain, and poor healing, routine repeat films are not necessary.
Chest radiographs should be taken after chest trauma to rule out complications such as pneumothorax and hemothorax (6,14)[B].
Rib series radiographs are not necessary for suspected isolated fractures of ribs 5–9.
Rib series radiographs are indicated if ribs 1–2 or ribs 9–12 are involved.
US has been used to diagnose and manage rib fractures (13)[B].
Rib series radiographs should be performed if there are suspected multiple rib fractures or pathologic fracture, the athlete is elderly, or there is preexisting pulmonary disease (15)[B].

P.247

With upper thoracic rib fractures, arteriography is indicated if there is evidence of vascular insufficiency, hemorrhage, or concomitant brachial plexus injury; marked displacement of the rib fragments; fractures of the scapula, vertebrae, or sternum; widening of the mediastinum; left apical cupping; or downward displacement of the left mainstem bronchus (10,5,8)[B].
ECG, echo, or stress testing if cardiac complications are considered
IV pyelogram if renal complications are suspected
Abdominal CT scan may be necessary if hepatic or splenic injury is suspected.

Differential Diagnosis

Rib/chest wall contusion
Muscle strain
Rupture of pectoralis major
Costochondral separation
Sternoclavicular separation
Costochondral sprain
Sternal fracture (anterior)
Intervertebral joint sprain
Intervertebral disc injury
Apophyseal joint sprain
Paraspinal muscle strain
Costovertebral joint sprain
Scheuermann disease (posterior)
Other causes of chest pain, such as cardiac causes, peptic ulcer disease, gastroesophageal reflux disorder, pneumothorax, pulmonary embolism, asthma, pleurisy, herpes zoster

Treatment

Treatment is generally supportive.
Pain control is the cornerstone of treatment and may be required for up to 3–6 wks after injury.
Ice and NSAIDs may control symptoms, but stronger oral pain medications often are required.
Local intercostal nerve blocks remain an option if other pain control techniques fail (9)[B].
Epidural anesthesia is also an option for pain control (13)[C].
Strapping or a chest binder has been advocated to help with pain. Caution should be exercised because immobilization techniques may result in inhibition of deep breathing, leading to atelectasis and possibly pneumonia (1,6,13)[C].
If immobilization is deemed necessary for comfort, its use should be minimized.

Additional Treatment

Additional Therapies

Flail chest occurs when ≥3 ribs are fractured in 2 locations.
Nonunion of rib fractures is rare but has been reported.
Rib stress fractures may respond well to rehabilitation exercises, such as push-ups, serratus press, upper extremity step-ups, and serratus rhythmic stabilization (1)[C].
Biomechanics of throwing, rowing, batting, or weight-lifting should be evaluated and corrected if necessary (2,11,16)[C].

Surgery/Other Procedures

Need for surgery is rare in cases of isolated rib fractures (6)[C]
Exception is in the case of flail chest. Open reduction internal fixation may be required (6)[C].
Suspected internal injuries associated with rib fractures should be referred for possible surgical repair.
Chronic pain due to recurrent stress fracture, nonunion, or recurrent dislocation or subluxation may improve with surgical excision of the involved rib (4)[B].

In-Patient Considerations

Admission Criteria

Patients over the age of 45 are at increased risk for complications, which may require hospitalization (6,14)[C].
Athletes with multiple rib fractures should be considered for admission to the hospital.

Ongoing Care

Follow-Up Recommendations

The athlete should be encouraged to continue activi-ties as tolerated, except for contact sports (7)[C].
Contact should be limited for the 1st 3 wks following injury. Consider rib protection in contact sports after return (1)[C].
Monitor regularly for signs of delayed complications (8)[B].

Patient Education

Athletes should be educated that it is common to have significant pain. They should not be reluctant to take pain medication early on. This allows for more normal breathing and less chance of complications like pneumonia (13)[C].
Athletes should be educated when to follow up. Especially if they experience fever, chills, worsening pain, dizziness, lightheadedness, fatigue, persistent cough, or respiratory distress.

Prognosis

Full healing usually takes 4–6 wks; however, athletes may return to participation in noncontact sports when pain-free.
Early return to contact sports may be possible prior to 6 wks if pain is controlled and the area can be protected adequately (13)[C].

Complications

Nonunioun of the ribs is rare in general. Symptomatic nonunion can occur and would be an indication for surgery (4,8,11)[B].
Pseudoarthrosis of the 1st rib is described in the literature and has been a cause for discontinued participation (4,8,11)[B].

References

1. Brukner P, Karim K. Clinical sports medicine. New York: McGraw-Hill, 1997.

2. Davis BA, Finnoff JT. Diagnosis and management of thoracic and rib pain in rowers. Curr Sports Med Rep. 2003;2:281–287.

3. Lord MJ, Ha KI, Song KS. Stress fractures of the ribs in golfers. Am J Sports Med. 1996;24:118–122.

4. Mithöfer K, Giza E. Pseudarthrosis of the first rib in the overhead athlete. Br J Sports Med. 2004;38:221–222.

5. George RB, Light RW, Matthay RA, eds. Chest medicine: essentials of pulmonary and critical care medicine. Baltimore: Williams & Wilkins, 1995.

6. DePalma AF. DePalma's the management of fractures and dislocations. Philadelphia: WB Saunders, 1981.

7. Miles JW, Barrett GR. Rib fractures in athletes. Sports Med. 1991;12:66–69.

8. Proffer DS, Patton JJ, Jackson DW. Nonunion of a first rib fracture in a gymnast. Am J Sports Med. 1991;19:198–201.

9. Orchard JW. Benefits and risks of using local anesthetic for pain relief to allow early return to play in professional football. Br J Sports Med. 2002;36:209–213.

10. Barrett GR, Shelton WR, Miles JW. First rib fractures in football players. A case report and literature review. Am J Sports Med. 1988;16:674–676.

11. O'Neal MO, Ganey TM, Ogden JA. First rib fracture and psuedoarthrosis in the adolescent athlete: The role of costosternal anatomy. Clin J Sports Med 2009;19:65–67.

12. Sakellaridis T, Stamatelopoulos A, Andrianopoulos E, et al. Isolated first rib fracture in athletes. Br J Sports Med. 2004;38:e5.

13. Karlson KA. Rib fractures. UpToDate. On-line: www.uptodate.com accessed 8/29/2009.

14. Kleckner K, DelRios M, Lewiss RE. Fracture of the third rib. Ann Emerg Med. 2008;51:e1–e2.

15. Smoljanovic T, Bojanic I. Ewing sarcoma of the rib in a rower: a case report. Clin J Sports Med. 2007;17:510–512.

16. Sik EC, Batt ME, Heslop LM. Atypical chest pain in athletes. Curr Sports Med Rep. 2009;8:52–58.

Additional Reading

O'Kane J, O'Kane E, Marquet J. Delayed complication of a rib fracture. Physician Sportsmed. 1998;26:69–77.

Rosen P, Barkin R, Danzl D, eds. Emergency medicine: concepts and clinical practice. St Louis: Mosby-Year Book, 1998.

Codes

ICD9

807.00 Closed fracture of rib(s), unspecified
807.09 Closed fracture of multiple ribs, unspecified
807.10 Open fracture of rib(s), unspecified

Clinical Pearls

To combat pain associated with fractured ribs, patients should:
- Start with icing.
- Sometimes pushing against and supporting the injured rib, especially with coughing or sneezing, will decrease pain.
- If necessary, a binder may be used for a very limited time.
In most cases of isolated rib fractures, simple chest films are all that are required. If the 1st or the bottom couple of ribs are involved, other x-rays may be ordered.
Patients should continue to be as active as they can tolerate and should not hesitate to take medication prescribed for pain.
- Collision or contact sports should be avoided until return to play is approved by a doctor, usually in 3 wks.
It is important allow the stress fracture to heal, as well as to determine what might have contributed to it. Training, technique, and nutritional status should all be evaluated. Once contributing factors are identified and corrected, patients can return to their previous level of activity.