Definition A rib fracture is disruption in any of the 12 rib bones that form the rib cage.

The disruption may be a single fracture of one rib, a single fracture of multiples ribs, or a rib or ribs may be broken into several pieces (comminuted fracture). The fractures are classified by location (i.e., rib number, right or left side of the body) and whether the ends of the broken rib are aligned (nondisplaced) or not (displaced). The fourth through ninth ribs are the most commonly fractured, and fractures of the eighth through twelfth ribs are often a marker for abdominal organ injuries. "Flail chest" occurs when three or more neighboring ribs are fractured in two or more places, or when the ribs separate from the costal cartilage (costochondral separation) that attaches the ribs to the breast bone (sternum). This creates an unstable section of chest wall that moves in the opposite direction with respect to the rib cage. For example, when the individual breathes in and the rib cage rises, the portion of the rib cage is part of the flail chest will actually fall.) This paradoxical respiratory movement compromises respiratory efficiency. Rib fractures are the most common type of chest injury. They are caused by blunt or open trauma to the chest. Rib fractures often result from motor vehicle accidents, crush injuries, and recreational or athletic injuries. In the elderly, diseases that weaken the bones (osteoporosis, osteopenia) make an individual more susceptible to rib fractures from a fall. An increased risk for rib fracture has been associated with hyperparathyroidism. Stress fractures of the ribs may be caused by prolonged paroxysms of coughing that increase pressure and motion of the chest wall (e.g., chronic obstructive pulmonary disease [COPD], pneumonia, whooping cough [pertussis]), or less commonly by repetitive movement of the upper extremities (e.g., rowing, golf, discus throwing). Risk: Individuals at risk for chest trauma from work, recreational or athletic pursuits are more likely to sustain a rib fracture. An increased risk for rib fracture has been associated use of steroid drugs (Nadalo). Seventy-two percent of rib fractures occur in men, possibly due to job requirements for heavy labor or participation in sport activities that create a greater risk for blunt trauma (Holcomb). Postmenopausal women are at higher risk for osteoporosis and thus at higher risk for rib fracture. Incidence and Prevalence: Rib fractures are common and often go unreported. They account for 10% of traumatic injuries and 14% of all chest wall injuries in the US. The incidence of flail chest is 10% to 15% of severe chest traumas (Nadalo). Rib fractures are common in individuals who survive cardiopulmonary resuscitation, especially in older adults. Source: Medical Disability Advisor Diagnosis

History: Often, there is a history of blunt force trauma to the chest, a motor vehicle accident, a fall, or violent coughing. Individuals may complain of pain when breathing, coughing, reaching, or using chest wall muscles. Individuals may report feeling a lump over the injured area or feeling a rib(s) move abnormally. Individuals with severe trauma may complain of the inability to breathe normally. A comprehensive health history should be obtained, including recent and prior illnesses and related treatment. Physical exam: Bruises (contusions) and cuts (lacerations) may be observed. Tenderness over a portion of the chest and displacement of ribs may be noted with palpation. Cardiac and respiratory function are assessed with a stethoscope. Changes in breath sounds may be heard (auscultated), crunching (crepitus) may be felt in the soft tissue around the fracture site (signifying air that has leaked out of the chest cavity and is trapped in the tissue), and abnormal movement of the chest wall (flail chest) may be noted. Other signs of respiratory insufficiency including rapid, shallow breathing, the use of accessory muscles in breathing, a bluish color to the skin (cyanosis), agitation, and anxiety. The physician will determine if there are other injuries involving the lungs, heart and blood vessels, abdominal organs, spine, shoulders, and extremities. Tests: Chest and rib x-rays are ordered to locate the fracture(s) and to determine if there are other injuries to the lungs. In severe trauma cases, CT and MRI are performed to evaluate soft tissue injury. Pulse oximetry is a non-invasive method that allows rapid determination of an individuals ability to get enough oxygen. Full arterial blood gas analysis may be used, but this requires removal of a sample of blood directly from the artery and can be uncomfortable. Other laboratory tests may be performed to evaluate an individuals health status. Source: Medical Disability Advisor Treatment Uncomplicated rib fractures with no associated injuries are treated symptomatically on an outpatient basis. This includes medications to decrease pain, such as nonsteroidal anti-inflammatory agents, analgesics, and narcotics. Suppression of a cough, if present, will decrease pain. Ice may be placed over the tender area to decrease swelling. Support from a rib belt, binder, or corset helps to decrease pain, but individuals who use these devices cannot breathe deeply. This leads to higher risk of pneumonia or partial lung collapse (atelectasis); therefore, their use is seldom recommended. An intercostal nerve block may be an option for severe pain. Candidates for hospitalization include those individuals who are cannot manage their secretions, individuals with abdominal injuries, and the elderly, especially when there is evidence of poor breathing (hypoventilation), increased carbon dioxide levels in the blood (hypercapnia), atelectasis, or pneumonia.

Rib fractures rarely require surgical management, unless they are part of a major trauma (e.g., crush injury) to the chest with multiple vascular and neurological complications. Surgical procedures include removal of bone fragments (rib resection) or use of fixation devices for rigid stabilization during healing such as open reduction-internal fixation (ORIF). Source: Medical Disability Advisor Prognosis Rib fractures treated with nonsurgical methods (conservative treatment) will heal in 6 to 10 weeks but may be quite painful during that period. In multiple trauma cases, complete recovery will include resolution of other injuries. When surgical intervention (ORIF) is required, the rib should heal in approximately 6 weeks if there are no underlying conditions affecting bone healing. Associated conditions such as injury to the major organs and vessels in the chest may take longer to heal than an isolated rib fracture. Source: Medical Disability Advisor Rehabilitation Physical therapy is indicated in those individuals with a fractured rib who present with a compromised respiratory system, advanced age, or functional limitations associated with postural muscles. The goal of rehabilitation is to decrease pain, prevent respiratory complications and restore function. Local application of heat or cold may provide temporary relief of discomfort, in conjunction with pharmacological treatment. There is evidence to support the use of a transcutaneous electrical nerve stimulator (TENS) for pain management in patients with uncomplicated minor rib fractures (Oncel). The physical therapist should instruct patients in deep-breathing exercises to promote full lung expansion, relieve intercostal muscle spasm, and mobilize lung secretions. Finally, shoulder and trunk gentle stretching exercises may relieve discomfort and promote chest expansion, functional shoulder mobility, and improved posture. FREQUENCY OF REHABILITATION VISITS Nonsurgical Specialist Fracture, Rib Physical Therapist Up to 6 visits within 3 weeks The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor Complications Individuals over age 45 with more than four rib fractures are at increased risk for pulmonary complications or spleen or liver lacerations sustained in conjunction with traumatic rib fracture. Pulmonary complications may include laceration of the lung tissue (parenchyma) by fracture fragments, introduction of air into the pleural cavity surrounding the lungs (pneumothorax), and bleeding into the pleural cavity surrounding the lungs (hemothorax), often from a lacerated artery. These types of complications may require chest surgery (thoracotomy). Although rare, penetration of the heart has been reported, resulting in pericardial or aortic hemorrhage. Individuals with chronic underlying respiratory illnesses such as COPD, emphysema, or asthma may need to be hospitalized for respiratory support and management. Other complications of severe rib fractures with multiple trauma include damage to organs such as the spleen, liver, heart, major blood vessels, or bones in the chest cavity. Pulmonary contusions occurs in 20% to 40% of individuals with rib fractures, and the incidence of liver injury associated with rib fracture is 10.7%, and spleen injury is 11.3% (Nadalo). Though rare, nonunion (failed union) of the fracture may occur. Source: Medical Disability Advisor Return to Work (Restrictions / Accommodations) Return to work will require job modification for upper body activities involving reaching, carrying, twisting, lifting, and overhead work. Individuals with rib fracture(s) may not be able to tolerate heavy aerobic exertion in any position because of difficulty breathing.