| disease | Rib Fracture |
| alias | Fracture of Rib |
Rib fractures account for approximately 61-90% of chest injuries. Different types of external trauma can result in rib fractures with distinct characteristics: Direct violence applied to a localized area of the chest causes rib fractures with inward displacement of the broken ends, which may puncture the intercostal vessels, pleura, and lungs, leading to hemothorax or pneumothorax. Indirect violence, such as compression of the chest from front to back, often causes fractures in the middle segment of the ribs, with outward displacement of the broken ends, injuring the soft tissues of the chest wall and resulting in a chest wall hematoma. Gunshot wounds or shrapnel injuries typically cause comminuted rib fractures. In children, ribs are highly elastic and less prone to fractures, whereas in adults, especially the elderly, the elasticity of ribs diminishes, making them more susceptible to fractures.
bubble_chart Clinical Manifestations
Occasionally, due to severe cough or sneezing, the chest muscles suddenly contract violently, leading to rib fracture, which is termed spontaneous rib fracture. This most commonly occurs in the 6th to 9th ribs in the axillary region. When the ribs themselves are affected by conditions such as primary or metastatic tumors, rib fracture can occur with minimal or no external force, known as pathological rib fracture.
Rib fractures most frequently involve the 4th to 7th ribs. The 1st to 3rd ribs are protected by the clavicle, scapula, and shoulder girdle muscles, making them less prone to fracture. The 8th to 10th ribs gradually shorten and connect to the costal cartilage arch, providing elastic cushioning and reducing the likelihood of fracture. The 11th and 12th ribs are floating ribs with greater mobility and rarely fracture. However, when subjected to significant force, any of these ribs can fracture.
Localized pain is the most prominent symptom of rib fracture, worsening with movements such as coughing, deep breathing, or body rotation. Some patients may even hear or feel a "clicking" sensation at the fracture site due to bone friction. The pain and compromised stability of the thoracic cage can restrict respiratory movement, leading to shallow and rapid breathing, reduced alveolar ventilation, and reluctance to cough, resulting in mucus retention. This can cause obstruction of lower respiratory tract secretions, pulmonary edema, or atelectasis, particularly concerning in elderly or debilitated patients or those with preexisting lung conditions. In flail chest, during inhalation, the increased negative intrathoracic pressure causes the softened chest wall to cave inward; during exhalation, the elevated intrathoracic pressure pushes the injured chest wall outward, creating a movement opposite to the rest of the chest wall, termed "paradoxical respiration." Paradoxical respiration can disrupt the balance of intrathoracic pressure between the two sides, causing the mediastinum to shift back and forth with each breath, known as "mediastinal flutter," which impairs venous return and leads to circulatory dysfunction, a significant factor in exacerbating shock. In flail chest, chest pain and thoracic instability are more severe, and paradoxical respiration further restricts respiratory movement, weakens coughing, reduces vital capacity and functional residual capacity (FRC), and decreases lung compliance and tidal volume, often accompanied by severe dyspnea and hypoxemia. It was once believed that in flail chest, some gas would oscillate between the healthy and injured lungs during inhalation and exhalation, failing to participate in gas exchange, termed "pendelluft" or "swinging air," which was thought to be the primary cause of respiratory dysfunction. However, current understanding suggests that pendelluft does not exist, and the pulmonary contusion often associated with flail chest—causing alveolar and interstitial hemorrhage, edema, alveolar rupture, and atelectasis—is the major contributor to respiratory impairment.
The diagnosis of rib fractures is primarily based on injury history, clinical manifestations, and chest X-ray examination. Applying pressure to non-fractured areas of the sternum or ribs (thoracic compression test) resulting in pain at the fracture site (indirect tenderness), or direct pressure on the rib fracture site causing direct tenderness, along with possible audible bone crepitus, palpable bone friction, or abnormal rib movement, are highly diagnostic. Chest X-rays can usually reveal rib fractures; however, fractures in the costal cartilage, "greenstick fractures," non-displaced fractures, or fractures in the middle ribs that overlap with other ribs on the X-ray may be difficult to detect. Clinical manifestations should be considered to avoid misdiagnosis. Rib fractures without associated injuries are termed simple rib fractures. In addition to injuries involving the pleura and lungs, which may lead to hemothorax or pneumothorax, rib fractures are often accompanied by other thoracic or extra-thoracic injuries, which should be carefully assessed during diagnosis. Fractures of the first or second ribs are often associated with clavicle or scapular fractures and may involve intrathoracic organ or major vascular injuries, bronchial or tracheal rupture, or cardiac contusion, as well as head trauma. Lower rib fractures may be associated with intra-abdominal organ injuries, particularly liver, spleen, or kidney rupture, and may also involve spinal or pelvic fractures. However, fractures of the seventh rib or below can irritate the intercostal nerves, causing referred abdominal pain, which should be differentiated from localized abdominal pain due to intra-abdominal organ injuries.
The treatment principles for simple rib fracture are pain relief, immobilization, and prevention of pulmonary infection. Analgesics can be administered orally or intramuscularly if necessary. Intercostal nerve block or trigger point injection provides effective pain relief and improves respiratory function, including effective coughing. For intercostal nerve block, 5 ml of 0.5% or 1% procaine is injected below the fractured rib, 5 cm lateral to the spine, covering the ribs immediately above and below the fractured rib. Trigger point injection involves direct injection of procaine into the fracture site, with 10 ml per site. If needed, the block or injection can be repeated every 12–24 hours, or long-acting analgesics may be used. Care should be taken to avoid deep puncture to prevent pleural membrane perforation. Semi-circular adhesive tape immobilization stabilizes the fracture and alleviates pain. This involves applying several 5–7 cm wide adhesive tapes in an overlapping shingle pattern from back to front and bottom to top during expiration, with 2–3 cm overlap and extending 3 cm beyond the midline. The immobilization should cover the ribs immediately above and below the fractured rib (Figure 5-3). However, due to suboptimal pain relief, restricted breathing, and potential skin allergies, this method is generally not recommended except during patient transport. Alternatively, a multi-strap chest binder or elastic chest bandage may be more effective. Preventing pulmonary complications primarily involves encouraging the patient to cough, sit up frequently, and assisting with sputum expectoration. Endotracheal suction may be necessary during seasonal epidemics. Appropriate antibiotics and expectorants should be administered.
For flail chest management, in addition to the above principles, special attention must be paid to promptly eliminating paradoxical breathing, maintaining airway patency, ensuring adequate oxygenation, correcting respiratory and circulatory dysfunction, and preventing shock. When the area of chest wall instability is small or located in the back, paradoxical breathing may not be significant, and local padding with pressure bandaging may suffice. However, if the flail segment exceeds 3 cm, severe respiratory and circulatory dysfunction can occur. A flail segment exceeding 5 cm or bilateral flail chest (flail chest syndrome) can rapidly lead to death and requires emergency intervention. Initial temporary padding and pressure bandaging should be followed by rib traction fixation. Historically, towel clip traction was commonly used: selecting 1–2 load-bearing ribs in the center of the flail segment, making small incisions above and below under local anesthesia, grasping the ribs with towel clips (avoiding injury to intercostal vessels and pleura), and applying 2–3 kg of weight traction via a pulley for about 2 weeks. Currently, various traction devices based on similar principles have been designed, replacing towel clips with specialized hooks and pulley traction with external fixation frames. These methods are simpler, allow patient mobility, and facilitate transport (Figure 5-4). For patients requiring thoracotomy, stainless steel wire fixation or Kirschner wire intramedullary fixation can be performed. Controlled mechanical ventilation to eliminate paradoxical breathing (internal pneumatic stabilization) is no longer routinely recommended for flail chest patients. However, for those with severe pulmonary contusion and acute respiratory failure, timely endotracheal intubation or tracheostomy with ventilator support remains critical.
Rib fractures typically heal spontaneously within 2–4 weeks, and unlike limb fractures, precise reduction is not emphasized. Simple rib fractures are not life-threatening. The focus of treatment lies in managing flail chest, addressing associated injuries, and preventing complications, particularly respiratory failure and shock.
Fractures of the first or second ribs are often associated with clavicle or scapula fractures, and may involve intrathoracic organs and major vascular injuries, bronchial or tracheal rupture, or cardiac contusion, frequently accompanied by craniocerebral trauma. Lower rib fractures may be associated with intra-abdominal organ injuries, particularly liver, spleen, and kidney rupture, and attention should also be paid to concurrent spinal and pelvic fractures.
