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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:
8 July 2022 17:03:45
Categories:
Trauma | Fractures | Spine - Thoracic | Acute | Overuse | Chest