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Rib Fracture
From WikiSM
Contents
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
- Pneumothorax
- Pulmonary Contusion
- Great Vessel Injury
- Hemothorax
- Bronchial Rupture
Pathoanatomy
- First Rib
- 180º arc from the T1 vertebra to the manubrium
- Overlays Subclavian Artery, vein
- Attachments include Scalenes, serratus Anterior, intercostal muscles
- Ribs 2-12
Risk Factors
- First rib fracture
- Overhead sports including rowing
- Stress Fractures: Sports
- Baseball[6]
- Rowing
- Contact Sports
- Football[7]
- Non-traumatic
- Amenorrhea
- Osteopenia / osteoporosis /Low bone mineral density
- Extreme overuse / repetitive use
- Repetitive coughing paroxysms
Differential Diagnosis
Differential Diagnosis Back Pain
- Fractures
- Neurological
- Musculoskeletal
- Autoimmune
- Infectious
- Pediatric
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
- Indications
- The majority of cases are nonsurgical
- Uncomplicated, solitary fracture
- General
- Rest[14]
- Ice
- Analgesia of rib fractures is notoriously challenging
- Oral analgesics including NSAIDS, Acetaminophen, Opiates
- May require/receive IV/IM/SubQ in ED or if hospitalized
- Topical analgesics
- Nerve blocks
- Multiple studies: improved pulmonary function, including tidal volume and maximal inspiratory force, enhanced analgesia, with overall better clinical outcomes when compared with treatment with systemic opioids[15]
- Intercostal Nerve Block
- Thoracic Epidural Block
- Paravertebral Block
- Serratus Plane Block
- Physical Therapy is indicated as pain resolves
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
- Up to 22%[18]
- Disability
- Up to 53%
Atraumatic
- Pseudoarthrosis
See Also
- Internal
- External
- Sports Medicine Review Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/
- Sports Medicine Review Back Pain: https://www.sportsmedreview.com/by-joint/back/
References
- ↑ Simon BJ, Cushman J, Barraco R, et al. Pain management guidelines for blunt thoracic trauma. J Trauma 2005;59:1256-67.
- ↑ 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
- ↑ 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.
- ↑ Alderson BR. Further observations on fracture of the first rib. Br J Radiol. 1947 Sep;20(237):345-50.
- ↑ 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.
- ↑ Miller, TL, Harris, JD, Kaeding, CC. Stress fractures of the ribs and upper extremities: causation, evaluation, and management. Sports Med. 2013;43:665–674.
- ↑ 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
- ↑ Kirsch MM, Sloan H. Injuries to the chest wall. In Blunt chest trauma, Little, Brown and Co, Boston, 1977
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ Yeh D, Kutcher M, Knudson M, Tang J. Epidural analgesia for blunt thoracic injury—which patients benefit most? Injury 2012; 43: 1667–71
- ↑ Diaz, J. J., et al. "Integrating surgical rib fixation into clinical practice: a report from the rib fracture consensus meeting." General Surgery News (2013).
- ↑ 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.
- ↑ Gordy, Stephanie, et al. "The contribution of rib fractures to chronic pain and disability." The American journal of surgery 207.5 (2014): 659-663.