Rib Fractures
Last updated 20th September 2019 - Tom Heaton
Rib fractures are a major traumatic injury.
They can result in significant complications for patients and so require careful assessment and management to minimise this.
They can result in significant complications for patients and so require careful assessment and management to minimise this.
Pathophysiology
Rib fractures are usually the result of fairly significant blunt thoracic trauma.
This is a fairly common feature of major trauma, thus rib fractures are found in around 10% of these patients.
Problems arise from:
Rib fractures are notoriously painful.
The requirement for ongoing breathing prevents the injury being rested, but the pain response can commonly limit the extent of breathing that a patient can do.
Deep breathing and coughing are frequently challenging.
The result of this, especially when combined with underlying lung contusion, is atelectasis and impaired sputum clearance.
This increases the risk of subsequent pneumonia, as well as their own impairment of gas exchange.
The force required to break ribs is generally adequate to result in significant underlying lung injury as well.
This is particularly true of extensive fractures and flail segments.
This contused lung will experience an inflammatory response, as well as localised haemorrhage and potentially necrosis.
All of these processes impair gas exchange.
These changes all contribute to impaired gas exchange and increased risk of infective complications.
The gas exchange is primarily one of V/Q matching, and so hypoxia predominates, with an increased respiratory rate usually compensating to maintain normocapnia.
However, this may not be the case in extensive injury.
A flail segment is defined as a fracture of 2 or more contiguous ribs in 2 or more locations.
This creates a portion of the thoracic wall that is essentially free-floating.
This can move paradoxically with inspiration and further impair respiratory mechanics.
Rib fractures on either side of the sternum have the potential to create a situation where the sternum is free floating.
The rib cage also provides some stabilising effect on the thoracic spine, and loss of this can make a potentially stable spinal fracture more unstable.
This is a fairly common feature of major trauma, thus rib fractures are found in around 10% of these patients.
Problems arise from:
- Pain
- Underlying lung injury
- Mechanical alteration to breathing
- Sequelae of above
Rib fractures are notoriously painful.
The requirement for ongoing breathing prevents the injury being rested, but the pain response can commonly limit the extent of breathing that a patient can do.
Deep breathing and coughing are frequently challenging.
The result of this, especially when combined with underlying lung contusion, is atelectasis and impaired sputum clearance.
This increases the risk of subsequent pneumonia, as well as their own impairment of gas exchange.
The force required to break ribs is generally adequate to result in significant underlying lung injury as well.
This is particularly true of extensive fractures and flail segments.
This contused lung will experience an inflammatory response, as well as localised haemorrhage and potentially necrosis.
All of these processes impair gas exchange.
These changes all contribute to impaired gas exchange and increased risk of infective complications.
The gas exchange is primarily one of V/Q matching, and so hypoxia predominates, with an increased respiratory rate usually compensating to maintain normocapnia.
However, this may not be the case in extensive injury.
A flail segment is defined as a fracture of 2 or more contiguous ribs in 2 or more locations.
This creates a portion of the thoracic wall that is essentially free-floating.
This can move paradoxically with inspiration and further impair respiratory mechanics.
Rib fractures on either side of the sternum have the potential to create a situation where the sternum is free floating.
The rib cage also provides some stabilising effect on the thoracic spine, and loss of this can make a potentially stable spinal fracture more unstable.
Assessment
This will be part of a major trauma approach and only the specifics relating to the rib fractures will be described here.
The presence of rib fractures may be felt likely through the mechanism of injury, and thus special attention in the examination directed towards them.
Pain on inspiration, as well as general localised pain may be reported by awake patients.
Examination may find:
The presence of rib fractures may be felt likely through the mechanism of injury, and thus special attention in the examination directed towards them.
Pain on inspiration, as well as general localised pain may be reported by awake patients.
Examination may find:
- Rib tenderness
- Crepitation on palpation
- Bruising
- Paradoxical chest movement in flail segment
Investigations
This may include:
A CXR may be performed in some scenarios, but may not identify all rib fractures.
Other major injuries may also be detectable this way.
Most patients with the mechanism of injury to break ribs will have a CT scan as part of their investigations.
This can provide more detailed information on the nature of the injuries.
- CXR
- CT
A CXR may be performed in some scenarios, but may not identify all rib fractures.
Other major injuries may also be detectable this way.
Most patients with the mechanism of injury to break ribs will have a CT scan as part of their investigations.
This can provide more detailed information on the nature of the injuries.
Severity Assessment
Assessment of the severity of the rib fractures is an important guide to subsequent management .
Key factors which have been shown to correlate with the severity are:
A Rib Fracture Score has been described to provide a composite representation of this:
Rib Fracture Score = (Breaks x Sides) + Age factor
Age Factor:
0 = <50
1 = 51-60
2 = 61-70
3 = 71-80
4 = >81
An increasing score denotes increasing severity and may be used to guide management e.g. analgesic choices.
However, it hasn’t been shown to have a strong predictive validity and local sites may have varying guidance for management.
Fractures of the 1st and 2nd ribs or scapula have required significant energy, and extra caution should be maintained if these injuries are identified.
Key factors which have been shown to correlate with the severity are:
- Number of fractures (not just number of ribs fractured)
- Bilateral > unilateral
- Patient age
A Rib Fracture Score has been described to provide a composite representation of this:
Rib Fracture Score = (Breaks x Sides) + Age factor
Age Factor:
0 = <50
1 = 51-60
2 = 61-70
3 = 71-80
4 = >81
An increasing score denotes increasing severity and may be used to guide management e.g. analgesic choices.
However, it hasn’t been shown to have a strong predictive validity and local sites may have varying guidance for management.
Fractures of the 1st and 2nd ribs or scapula have required significant energy, and extra caution should be maintained if these injuries are identified.
Management
As noted, these injuries are commonly part of a major trauma picture, and so need consideration alongside other injuries.
The components of rib fracture management specifically can generally be considered as:
The components of rib fracture management specifically can generally be considered as:
- Analgesia
- Supportive care
Analgesia
As noted, these are notoriously painful injuries.
Obtaining effective analgesia is important to allow more effective coughing and deep breathing and thus reducing the risk of the vicious circle of pathophysiological effects.
As with other forms of pain, a ladder of analgesic options can be envisaged:
Simple analgesia options are generally straightforward and well understood.
Paracetamol is a very benign starting part, and NSAIDs can be considered in the absence of contraindications because of their effectiveness.
A gabapentinoid may be added at a later stage to assist with reducing opioid requirements.
Opioids will often be required in addition to simple analgesia.
These will also be of a scale, ranging from weak opioids, through to oral opioids (regular and breakthrough, through to an opioid PCA.
Side effects should be anticipated and managed appropriately (antiemetics, laxatives).
Regional anaesthetic options may be considered in cases of severe fractures with significant symptoms or who are struggling with other analgesic options.
Techniques that have been employed include:
Obtaining effective analgesia is important to allow more effective coughing and deep breathing and thus reducing the risk of the vicious circle of pathophysiological effects.
As with other forms of pain, a ladder of analgesic options can be envisaged:
- Simple analgesia
- Opioids
- Oral
- PCA
- Oral
- Regional anaesthesia
Simple analgesia options are generally straightforward and well understood.
Paracetamol is a very benign starting part, and NSAIDs can be considered in the absence of contraindications because of their effectiveness.
A gabapentinoid may be added at a later stage to assist with reducing opioid requirements.
Opioids will often be required in addition to simple analgesia.
These will also be of a scale, ranging from weak opioids, through to oral opioids (regular and breakthrough, through to an opioid PCA.
Side effects should be anticipated and managed appropriately (antiemetics, laxatives).
Regional anaesthetic options may be considered in cases of severe fractures with significant symptoms or who are struggling with other analgesic options.
Techniques that have been employed include:
- Thoracic epidural
- Serratus anterior block
- Paravertebral block
- Intercostal blocks
Thoracic Epidural
This is probably the standard of care for severe rib fractures when other analgesia options are inadequate.
They are particularly useful in patients with fractures that are:
The level of insertion should aim to be that of the middle fractured rib.
The volume of local anaesthetic will be somewhat dependent on the extent of rib fractures, as this the distance that it needs to spread.
The choice of local anaesthetic agent (concentration and use of opioid) will be more dependent on local practices.
Close monitoring is required for the duration of the time that it is being used to assess for complications.
They are particularly useful in patients with fractures that are:
- High level
- Multiple
- Bilateral
- Resulting in resp compromise
- Improved analgesia
- Better tidal volumes
- Reduced pneumonia rates
- Reduced mortality
The level of insertion should aim to be that of the middle fractured rib.
The volume of local anaesthetic will be somewhat dependent on the extent of rib fractures, as this the distance that it needs to spread.
The choice of local anaesthetic agent (concentration and use of opioid) will be more dependent on local practices.
Close monitoring is required for the duration of the time that it is being used to assess for complications.
Paravertebral Block
These are an alternative to thoracic epidural analgesia.
A single catheter is able to provide unilateral cover for around 6 ribs.
Additional catheters can be sited, with caution needing to be given regarding the safe amount of local anaesthetic.
This reduced effect area may make them a less desirable option for some patients.
However, there is evidence demonstrating comparable results compared with epidurals, whilst avoiding some of the adverse features.
The limited epidural spread should reduce the risk of both sympathetic blockade, and the motor blockade associated with epidurals.
A large volume of LA is recommended to aid the appropriate spread (bearing in mind toxic doses) with 40ml of 0.25% levobupivacaine being an example described for a unilateral block.
Infusions via a catheter can then be continued for up to 7 days, with the patients able to mobilise with the catheter in.
This is a good video on the block: https://www.youtube.com/watch?v=vSbhqR5oIAs
A single catheter is able to provide unilateral cover for around 6 ribs.
Additional catheters can be sited, with caution needing to be given regarding the safe amount of local anaesthetic.
This reduced effect area may make them a less desirable option for some patients.
However, there is evidence demonstrating comparable results compared with epidurals, whilst avoiding some of the adverse features.
The limited epidural spread should reduce the risk of both sympathetic blockade, and the motor blockade associated with epidurals.
A large volume of LA is recommended to aid the appropriate spread (bearing in mind toxic doses) with 40ml of 0.25% levobupivacaine being an example described for a unilateral block.
Infusions via a catheter can then be continued for up to 7 days, with the patients able to mobilise with the catheter in.
This is a good video on the block: https://www.youtube.com/watch?v=vSbhqR5oIAs
Serratus Anterior Plane Block
This is another regional technique that has a few advantages over the others described.
Injection of local anaesthesia into this plane can block the intercostal nerve innervation of the anterior hemithorax of levels T2-9.
There are very few contraindications, compared to the other techniques above, making this an option in some of the cases where an epidural or paravertebral may not be possible e.g. vertebral fractures.
Bilateral blocks can be performed and catheters may be inserted and used for up to 7 days.
It is also a technically easier block than the others.
This is a good video of this block: https://www.youtube.com/watch?v=lVS7QonwTU8
Injection of local anaesthesia into this plane can block the intercostal nerve innervation of the anterior hemithorax of levels T2-9.
There are very few contraindications, compared to the other techniques above, making this an option in some of the cases where an epidural or paravertebral may not be possible e.g. vertebral fractures.
Bilateral blocks can be performed and catheters may be inserted and used for up to 7 days.
It is also a technically easier block than the others.
This is a good video of this block: https://www.youtube.com/watch?v=lVS7QonwTU8
Other
Intercostal blocks can provide effective analgesia for up to 24 hours, but are limited by their locality.
This means that multiple injections are needed to help with multiple fractures, each being associated with the risk of bleeding, infection and pneumothorax.
Intrapleural blocks are no longer usually employed due to their relative ineffectiveness (positioning nature, LA coming out of drain) and high systemic uptake of LA.
This means that multiple injections are needed to help with multiple fractures, each being associated with the risk of bleeding, infection and pneumothorax.
Intrapleural blocks are no longer usually employed due to their relative ineffectiveness (positioning nature, LA coming out of drain) and high systemic uptake of LA.
Surgical Fixation
The surgical fixation of ribs has come in and out of fashion over the years.
The challenges compared to the fixation of other bony injured include:
The challenges compared to the fixation of other bony injured include:
- The challenging shape (conical and twisting)
- Thin cortex
- Repeated stress of ventilation
- Surgical access - can require painful incisions
- Intubated patients with
- Flail chest
- Prolonged ventilation
- Respiratory compromise
- Flail chest
- Deteriorating respiratory status with flail segment (non-intubated)
- Thoracotomy for other indications
- Analgesic failure
- Rib non-union
- Lower rates of pneumonia
- Reduced critical care admissions/fewer ventilator days
- Reduced mortality
- Reduced opioid requirements
Links & References
- May, L. et al. Rib fracture management. BJA Education. 2-16. 16(1): 26-32. https://academic.oup.com/bjaed/article/16/1/26/2463139
- Tucker, R. Serratus anterior plane block. Youtube. 2019. https://www.youtube.com/watch?v=lVS7QonwTU8
- LSORA. Paravertebral block (US guided) tutorial. Youtube. 2015. https://www.youtube.com/watch?v=vSbhqR5oIAs
- Nickson, C. Thoracic trauma. LITFL. 2019. https://litfl.com/thoracic-trauma/
- Bersten, A. Soni, N. (eds). Oh’s Intensive Care Manual (7th ed). Butterworth Heinemann Elsevier.
- Trauma.org. http://www.trauma.org/archive/thoracic/CHESTflail.html
