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Rib Fracture

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Other Names

  • First rib fracture
  • Stress fracture of the rib
  • Rib stress fracture
  • Chondral Rib Fractures

Background

  • This page describes fractures of the Ribs
    • Acute, traumatic (most common)
    • Acute, non-traumatic
    • Chronic, non-traumatic (stress fracture)
    • Severe rib contusions can present like fracture

History

Epidemiology

  • The most common serious injuries of the chest, account for 2/3 of traumatic thoracic injuries[1]
    • In the United States, there was an estimated 300,000 cases in 2004, which increased to 350,000 cases in 2017[2]
    • Roughly 1/3 are admitted to the hospital
  • Uncommon in children due to flexibility, elasticity of thorax
  • In Athletes
    • Estimated 4 chondral cartilage fractures in 5 years per NFL team or 0.8 per year[3]
  • First rib fractures are rare
    • 72 noted in 77,607 consecutive radiographs of servicemen[4]

Pathophysiology

  • Traumatic
    • Typically blunt trauma
    • Most commonly in the middle, lower ribs
    • Associated with significant morbidity, mortality
  • Less commonly, acute non-traumatic from stretching
  • Less commonly, insidious, non-traumatic stress injury from repetitive tasks
  • Chondral Rib Fracture: fracture occurs in the costal cartilage between the anterior osseous margin and the sternum
    • Uncommon, best described in American Football players

Etiology

  • Direct force in the anterior-posterior plane
    • As the radius of the ribs increases, tension increases laterally
    • Most commonly affected ribs are 5th-9th (need citation)
  • Direct force over small area of chest wall
  • Violent muscle contraction

First Rib Fracture

  • Uncommon rib fracture due to it being well protected by other anatomic structures
    • Typically due to severe, direct trauma
    • Carries a risk of serious visceral, vascular, or neurologic associated injuries
  • In athletes
    • Non-traumatic rib fractures have been reported with stretching[5]
    • Reported in the following sports: swimming, baseball, football, soccer, tennis, powerlifting, rowing, lacrosse, martial arts, basketball, and surfing
    • Can be insidious or acute

Stress Fracture

  • Due to repetitive contraction, muscle fatigue and sites of anatomic weakness

Associated Conditions

Pathoanatomy

Risk Factors

  • First rib fracture
    • Overhead sports including rowing
  • Stress Fractures: Sports
    • Baseball[6]
    • Rowing
  • Contact Sports
  • Non-traumatic
    • Amenorrhea
    • Osteopenia / osteoporosis /Low bone mineral density
    • Extreme overuse / repetitive use
    • Repetitive coughing paroxysms

Differential Diagnosis

Differential Diagnosis Back Pain

Differential Diagnosis Chest Pain

Clinical Features

  • General: Physical Exam Back, Physical Exam Chest
  • History
    • Usually a history of trauma
    • Localized pain, worse with coughing, inspiration
    • Insidious onset is seen with stress injuries (rarely, patients may report a hearing a "snap")
    • First rib fractures (traumatic or atraumatic) often present as shoulder or back pain
  • Physical
    • With first rib fractures, cervical ROM intact
    • Bruising over fracture site
    • Pain to palpation over fractured rib
    • May feel crepitus if there is air in the soft tissue
    • First rib fracture findings are more subtle and nonspecific

Evaluation

Radiographs

  • Typically start with Chest Radiographs
    • Rib fractures with be identified on AP film about 90% of the time [8]
    • Another study reported that xrays miss 60% of rib fractures of any etiology (need citation)
  • May also obtain Rib Series to better evaluate ribs after screening with the chest xray
  • Only 20% of first rib fractures are seen on chest radiographs[9]

CT

  • More sensitive for first rib fracture (need citation)
  • Helpful for pathologic fractures, better evaluate bone
  • In limited case series, used to identify chondral rib fractures

MRI

  • Most useful in the setting of insidious onset and suspicion for stress injuries with negative radiographs
  • MRI is challenging due to the small cross-sectional diameter of the ribs and long scan times

Classification

1st Rib Stress Fracture

  • Groove type (12.5%)
  • Intrascalene type (75%)
  • Posterior type (12.5%)

Management

Prognosis

  • In patients with flail chest, patients have better outcomes with surgical than nonsurgical management[10]
  • Girsowicz et al: surgery can alleviate post-operative pain in non-flail chest rib fractures[11]
    • Forced vital capacity at 12 months is greater, more people return to work, and the incidence of chronic pain reduced[12]
  • 2005 German study concluded that both surgical and nonsurgical treatments show improved blood analysis, and there was no difference in mortality[13]

Nonoperative

Operative

  • Rarely surgical
    • In Chinese cohort, only 2-3% of rib fractures were managed surgically (need citation)
  • Indications (some are controversial)[16]
    • Flail chest
    • 3 continuous rib fractures with significant displacement
    • Worsening chest xray
    • Need for mechanical ventilation
    • Use of IV narcotics
    • Uncontrolled pain when using analgesia or VAS score >6
    • Lung impalement
    • Open chest defect
    • Stabilization on the retreat of thoracotomy
    • Pulmonary herniation
  • Technique
    • ORIF

1st Rib Fractures

  • Rest, analgesia
  • Rarely surgical excision

Stress Fractures

  • Relative rest, analgesia, cessation of all provocative activities for 4-6 weeks
  • Correct faulty training mechanics
  • Correct any metabolic dysfunction
  • Slow return to play

Rehab and Return to Play

Rehabilitation

  • Physical Therapy is indicated as pain resolves
    • 1st rib: regain shoulder motion, strength

Return to Play

  • Restricted contact for 3 weeks
    • May participate in non-contact activities as tolerated
  • Rib Protector or flak jacket worn for 6-8 weeks [17]
    • Typically not well tolerated by athletes
    • Newer versions are lower profile

Complications

Traumatic

  • Chronic Pain
  • Disability
    • Up to 53%

Atraumatic

  • Pseudoarthrosis

See Also

References

  1. ↑ Simon BJ, Cushman J, Barraco R, et al. Pain management guidelines for blunt thoracic trauma. J Trauma 2005;59:1256-67.
  2. ↑ Pieracci FM, Majercik S, Ali-Osman F, et al. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017;48:307-21
  3. ↑ McAdams, Timothy R., et al. "Chondral rib fractures in professional American football: two cases and current practice patterns among NFL team physicians." Orthopaedic journal of sports medicine 4.2 (2016): 2325967115627623.
  4. ↑ Alderson BR. Further observations on fracture of the first rib. Br J Radiol. 1947 Sep;20(237):345-50.
  5. ↑ Weis, Jamie L. "Nontraumatic First Rib Fractures Secondary to Opposing Muscle Contractions: A Case Series." JBJS Journal of Orthopaedics for Physician Assistants 7.3 (2019): e0009.
  6. ↑ Miller, TL, Harris, JD, Kaeding, CC. Stress fractures of the ribs and upper extremities: causation, evaluation, and management. Sports Med. 2013;43:665–674.
  7. ↑ 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
  8. ↑ Kirsch MM, Sloan H. Injuries to the chest wall. In Blunt chest trauma, Little, Brown and Co, Boston, 1977
  9. ↑ Luceri RE, Glass NE, Bailey JA, Sifri ZC, Kunac A, Bonne SL, Yonclas PP, Mosenthal AC, Livingston DH. First rib fracture: a harbinger of severe trauma? Am J Surg. 2018 Oct;216(4):740-4. Epub 2018 Jul 24.
  10. ↑ Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52:727-32; discussion 732.
  11. ↑ Girsowicz E, Falcoz PE, Santelmo N, et al. Does surgical stabilization improve outcomes in patients with isolated multiple distracted and painful non-flail rib fractures. Interact Cardiovasc Thorac Surg 2012;14:312-5.
  12. ↑ Hasenboehler, Erik A., et al. "Treatment of traumatic flail chest with muscular sparing open reduction and internal fixation: description of a surgical technique." Journal of Trauma and Acute Care Surgery 71.2 (2011): 494-501.
  13. ↑ Granetzny A, Abd EM, Emam E, et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005;4:583-7.
  14. ↑ Chistopher Kim, S. K. (2020 ). Commonly Encountered Fractures in Sports Medicine. In S. T. Mark Miller, DELEE, DREZ, & MILLER'S ORTHOPAEDIC SPORTS MEDICINE, FIFTH EDITION (pp. 131-142.e4). Philadelphia: Elsevier
  15. ↑ Yeh D, Kutcher M, Knudson M, Tang J. Epidural analgesia for blunt thoracic injury—which patients benefit most? Injury 2012; 43: 1667–71
  16. ↑ Diaz, J. J., et al. "Integrating surgical rib fixation into clinical practice: a report from the rib fracture consensus meeting." General Surgery News (2013).
  17. ↑ M. Patrice Eiff, R. H. (2018). Rib Fractures. In R. H. M. Patrice Eiff, Fracture Management for Primary Care Updated Edition, Third Edition (pp. 341-345). Philadelphia: Elsevier Saunders.
  18. ↑ Gordy, Stephanie, et al. "The contribution of rib fractures to chronic pain and disability." The American journal of surgery 207.5 (2014): 659-663.
Created by:
John Kiel on 13 June 2019 07:09:30
Authors:
Last edited:
5 October 2022 23:56:45
Categories:
Trauma | Fractures | Spine - Thoracic | Acute | Overuse | Chest

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