Rib Fractures

The chest cavity contains your heart and lungs, organs that could be easily injured if not protected. Your ribs form a protective armor around these organs, absorbing blunt trauma that could otherwise cause major damage. Ribs may fracture when subjected to force, resulting in pain and difficulty with breathing.

 
In the U.S., 300,000 rib fractures are diagnosed and treated every year, with a small (7%) number resulting in hospitalization and, sometimes, surgical intervention. Trauma that is severe enough to fracture a rib can cause damage to the heart, lungs, blood vessels, and upper abdominal structures like the liver, diaphragm, kidneys, and spleen, depending on the location.

 
RIB CAGE ANATOMY

 
You have 12 pairs of ribs. These are sometimes characterized as “true ribs”, “false ribs”, and “floating ribs”. The true ribs (ribs 1-7) connect via flexible cartilage to the breastbone, or sternum. False ribs (8-10) connect to the sternum at the cartilage of the 7th rib. The 11th and 12th ribs “float” anteriorly, with no connection to the breastbone. All ribs connect to the thoracic spine in back. Ribs are also connected to each other by muscles (called “intercostal” muscles).

 
SIGNS AND SYMPTOMS OF RIB FRACTURES

 
If a rib is broken, several signs and symptoms are likely to appear. You can suspect a rib fracture if you note the following:

 
• Pain at the site of injury
• Increased pain with breathing or movement
• Bruising of the chest or back over the ribs
• Grating sensation or sound when fractured bone ends rub against each other (also known as “bone crepitus”)
• Splinting, or the tensing of muscles in an effort to decrease pain

 
In uncomplicated single fractures, there is often no change in the appearance of the chest wall. More serious or multiple fractures may present with:

 
• Rapid, shallow breathing
• Rapid heart rate
• Hemoptysis (coughing up blood) or blood in the urine
• Irregular appearance at the site of injury (bump or indentation)
• Assymetrical movement of the chest wall (sign of a condition called “Flail Chest”.

 
A flail chest occurs when several adjacent ribs are fractured. It can be identified by placing one hand on each side of the chest, and observing movement during breathing. The uninjured side will rise during inspiration, but the flail injury will fall. This occurs because the “loose” segments of rib cage are pulled into the chest cavity when inhaling, increasing the work of breathing. Flail chest injuries often cause pulmonary contusions, a bruising of the lungs that interferes with oxygenation. Often, the patient requires ventilator support and will do poorly in austere settings.

 
Serious fractures may puncture the lung, causing it to collapse, or cause internal bleeding. Efforts by the victim to limit pain by avoiding deep breathing may result in pneumonia, poor oxygenation, and even partial collapse (also called “atelectasis”). Treatment of a punctured lung will be discussed in a future article.

 
TREATING A RIB FRACTURE

 
In normal times, any patient with a suspected rib fracture should be taken immediately to a modern medical facility. The major goal of treatment is pain control. By decreasing the victim’s pain during breathing, you will preserve normal ventilation and prevent lung complications. The most commonly used medications are non-steroidal anti-inflammatory agents like Ibuprofen or Naproxen, although they may have risks if there is internal bleeding.

 
If an injury occurs in the wilderness, the patient should be placed in a lateral position on the side where the injury occurred. Ice packs, if available, will help relieve discomfort. They should be applied for 20 minutes each hour the first 48 hours after the injury, and as needed afterwards. Limit activities that cause pain, but the patient should not be bedridden. Some recommend slinging the arm on the side of the injury with a soft pack of spare clothes for support.

 
Previously, fractured ribs were treated with a binder called a “rib belt”. Although this method relieves some pain, it has since been determined to cause more harm than good by preventing the ability to take deep breaths. Although wrapping the chest is no longer done, some practitioners still suggest placing 4 or 5 strips of tape parallel to each other over the area of the injury. If you must do this, only tape one side from the spine to the sternum and observe for any restriction of breathing. Remember that, if a rib is displaced inward, any binding may push it further into the chest cavity.

Prevent pneumonia or lung collapse due to “underbreathing” by encouraging slow deep breathing exercises and gentle coughing every 2 hours or so. Your patient will experience less pain during this process by holding a blanket or pillow against the site of injury. Signs of pneumonia will include fever and cough.

 
In situations where the rib segments are displaced, titanium plates are sometimes attached surgically to provide support and protect from further injury. This is required only in a small percentage of injuries. Healing from a rib fracture usually takes about 6 weeks, but the patient may not be pain-free until much later.

Have you fractured a rib during your travels?  Let us know about your experiences in the comments section!

Joe Alton, M.D.

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