CHEST INJURIES - FRACTURED RIB

DEFINITIONS
Chest Injury:- Is an injury that can occur as a result of an accidental or deliberate penetration of a foreign
object into the chest. This type of injury can also result from a blunt trauma, leading to chest wall injury
(causing rib bruises, fracture, lung or heart contusions).

A Rib:- Is any one of the 12 pairs of long flat curved bones of the thorax, each united by cartilage to the
spinal vertebrae of the back.

A Fractured Rib or Broken Rib:- Is a common injury that occurs when one of the bones in the rib cage
breaks or cracks.

Many broken ribs are merely cracked. While still painful, cracked ribs are not as potentially dangerous as
ribs that have been broken. In these situations, a jagged piece of bone could damage major blood vessels or
internal organs, such as the lungs. In most cases, broken ribs heal on their own in one or two months.
Adequate pain control is important, so you can continue to breathe deeply and avoid lung complications,
such as pneumonia.

FUNCTION OF THE RIB

The ribs have two main functions:
 They protect the organs in the chest.
 They help in breathing by keeping space open inside the chest. While the muscles use to breathe
squeeze in, or contract it leaves plenty of space for the lungs to fill up with air.

PATHOPHYSIOLOGY
The chest wall protects underlying sensitive structures by surrounding internal organs with hard osseous
(bony) structures including the ribs, clavicles, sternum, and scapulae. An intact chest wall is necessary for
normal respiration. There are 12 ribs on each side of the normal human thorax (24 ribs in total) that function
to protect the intrathoracic organs and to aid in respiration. The first 2 ribs are shorter than ribs 3 through
to10 and are intimately associated with the subclavian artery and the brachial plexus. Injuries to these 2 ribs
should alert the physician to the possibility of vascular or neurological injury. Fractures of ribs 4 through to
10 can be single, segmental, or multiple. These injuries are the direct result of a significant force, resulting in
fracture and often displacement of the rib fragments. As a result, these rib fragments have the potential to
injure the pleural or intra-abdominal viscera. Upper rib injuries tend to injure the lung parenchyma by direct
penetration.
Rib fractures may compromise ventilation by a variety of mechanisms. Pain from rib fractures can cause
respiratory splinting, resulting in atelectasis and pneumonia. Multiple contiguous rib fractures (ie, flail chest)
interfere with normal costovertebral and diaphragmatic muscle excursion, potentially causing ventilatory
insufficiency. On the inferior surface of each rib are the intercostal nerve, artery, and vein. This
neurovascular bundle has the potential to be injured with fractures of the rib, with the fragment penetrating
other organs resulting in the formation of a pneumothorax or a hemothorax and substantial pulmonary
insufficiency. Ribs commonly fracture at the point of impact or at the posterior angle (structurally their
weakest area). Ribs four through nine (4-9) are the most commonly injured.
Ultimately, rib fractures impair adequate ventilation, resulting in atelectasis, poor oxygenation and
respiratory compromise. Ribs and costal cartilage are more elastic in children, making substantial force
necessary to cause a fracture. Therefore, in the absence of a known traumatic event, non-accidental injury
should be suspected, as up to 82% of patients in this category are victims of physical abuse.

CAUSES
Broken ribs can be caused by direct impact or repetitive trauma.
Direct Impact
 Motor vehicle accidents
 Falls
 Child abuse
 Contact sports

Repetitive Trauma
 Sports such as golf or rowing
 Severe and prolonged coughing spells

SYMPTOMS
A fractured rib may cause:
 Mild to severe pain in the injured area.
 Pain when taking a deep breath.
 Pain around the fracture that gets worse when the breastbone is pressed, bending or twisting the
body.
If patient can't breathe normally because of pain or flail chest, he may:
 Feel shortness of breath.
 Feel anxious, restless, or scared.
 Have a headache.
 Feel dizzy, tired, or sleepy.

RISK FACTORS
The following factors can increase risk of breaking a rib:
 Osteoporosis:- A disease in which the bones lose their density, makes one more susceptible to a bone
fracture.
 Sports Participation:- Participating in contact sports, such as hockey or football, increases the risk of
trauma to the chest and the trauma increases the risk of rib fractures.
 Cancerous Lesion in a Rib:- A cancerous lesion can weaken the bone, making it more susceptible to
breaks.
DIAGNOSIS
 Physical examination. The doctor may:
 Push on the chest to find out where it hurts.
 Watch patient breathe and listen to lungs to make sure air is moving in and out normally.
 Listen to the heart beat.
 Check the head, neck, spine, and belly to make sure there are no other injuries.
 Chest X-ray
 Computerized tomography
 Magnetic resonance imaging (MRI)
 Bone scan (to view stress fractures, where bone is cracked after repetitive trauma).

TREATMENT

The mainstay of treatment for rib fractures is to provide the patient with adequate analgesia coupled with
meticulous respiratory care in order to prevent complications such as atelectasis and pneumonia.
Single Rib Fractures
Patients with isolated rib fracture without other associated injury may be treated as out-patients. Patients
should be made aware that pain could last for up to eight weeks, therefore during this time adequate oral
analgesia should be prescribed. A non-steroidal anti-inflammatory drug (NSAID) and a combination drug
such as co-codamol (unless contraindicated) is normally prescribed. A physiotherapist should emphasise to
patients the importance of deep breathing and coughing to clear phlegm from the chest. To ease the pain of
coughing, patients may support the rib area with their hands, a towel or a pillow. Any strenuous activities
should be avoided for the first three to four weeks following the fracture, but after this, physical exercise can
be undertaken as pain allows. No attempt should be made by a patient to participate in contact sports for six
weeks so as to avoid the possibility of further damage.
NB// Patients should be advised that if they develop fever, uncontrollable cough, abdominal pain, have
increased difficulty breathing or cough up thick or discoloured sputum they should contact their
doctor or a hospital urgently. Elderly patients with a single fracture or those with cardiopulmonary
disease may require hospitalisation, as there is evidence of an increased risk of complications in these
patient groups.
Multiple Rib Fractures
Patients with multiple fractures will require admission to a trauma ward or a high dependency unit
depending on the severity of the injury. Initial care will focus on multi-system evaluation and stabilisation,
adequate pain relief and physiotherapy. In rare cases, surgical stabilisation is necessary using Kirschner
wires and in serious complications Thoracotomy is necessary.

PAIN MANAGEMENT
Effective management of acute pain relies on accurate and appropriate assessment of the patient’s pain. The
assessment should systematically record pain intensity on movement using a recognized tool that requires
patient involvement.
Epidural analgesia is a particularly effective method of pain control as it provides an excellent level of pain
relief with minimum sedation. It has also been shown to improve pulmonary function and reduce morbidity
associated with multiple rib fractures. Epidural analgesia involves the administration of agents into the
epidural space. Giving a combination of a local anaesthetic, for example, bupivacaine, and an opioid, for
example fentanyl, via an epidural catheter is synergistic, therefore achieving the desired analgesic effect
while potentially reducing the possibility of unwanted side-effects.
Patient-controlled analgesia is a useful alternative to the administration of epidural analgesia and allows
parenteral administration of opioid analgesia (that is, morphine). It is a safe method of analgesic delivery,
and has significant benefits over conventional methods such as intramuscular injections. It also allows the
patient to control the amount of analgesia required at any one time; for example, before having
physiotherapy. Some patients, however, are unable to grasp the concept of patient-controlled analgesia, in
which case an alternative method of analgesia will be required.
Intercostal nerve block can provide an excellent level of pain relief, allowing patients to cough and undergo
physiotherapy with minimal discomfort. The drawback of this method is that the block would have to be
given by anaesthetic staff approximately every 12 hours.
A multi-modal approach is the most effective way of controlling pain. Paracetamol has beneficial effects,
particularly when used in combination with other drugs, it enhances analgesia and has a morphine-sparing
effect when given regularly in combination with patient-controlled analgesia. NSAIDs such as diclofenac or
ibuprofen inhibit the activity of cyclo-oxygenase and therefore prevent the production of inflammatory
mediators or prostaglandins and the swelling associated with bone injury and surrounding tissue damage.
However, caution must be employed because it is known that NSAIDs reduce osteoblast (bone-forming cell)
activity. Discontinuation of the drug should therefore be considered if any signs of delayed bone union are
noted during the recovery period.

NSAIDS are contraindicated in some patients; for example, those who have previously had gastrointestinal
disturbances including ulceration, who have impaired renal function, impaired coagulation problems, liver
damage or central nervous system disturbance (Jordan and White, 2001). The newer COX II inhibitors such
as rofecoxib or celecoxib may be suitable alternatives for these patients.

PHYSIOTHERAPY
Aggressive pain management techniques, such as epidural analgesia, need to be employed before patients
have physiotherapy. The aim of physiotherapy for a patient with multiple fractured ribs is to minimise any
compromise of the respiratory system. An initial assessment is carried out to obtain a set of baseline
objective markers from which to develop a treatment programme; these include respiratory rate, oxygen
saturation, breathing pattern, peak expiratory flow rate, arterial blood gases, and auscultation (listening to
chest sounds). Treatment is carried out at a minimum of twice a day for the first three days and then on an
‘as required’ basis. At each session the patient is reassessed and the initial objective markers re-tested.

NURSING MANAGEMENT
If there are other internal injuries along with a fractured rib are treated with strong medicine to control pain.
Mild fractured ribs are treated with analgesics and heal on their own over time. Pain relief can help one feel
better and let one take deeper breaths. A fractured rib usually takes at least 6 weeks to heal. To help manage
the pain while the fracture heals:
 Put ice on the injured area.
 Allow patient to get enough rest.
 Serve pain medicine as prescribed such as aspirin or ibuprofen.
 Encourage patient to do coughing and deep breathing exercises at least once an hour to prevent
pneumonia or partial collapse of the lung tissue.
 Support injured side with towel or pillow to enhance deeper breathes.

EDUCATION
 Educate patient to avoid any strenuous activities for the first three to four weeks following the
fracture, but after this, physical exercise can be undertaken as pain allows.
 No attempt should be made by a patient to participate in contact sports for six weeks so as to avoid
the possibility of further damage.
 Patients should be advised that if they develop fever, uncontrollable cough, abdominal pain have
increased, difficulty breathing or cough up thick or discoloured sputum they should contact their
doctor or a hospital urgently.

COMPLICATIONS
 Pneumothorax
 Haemothorax
 Emphysema
 Atelectasis
 Hypoventilation
 Hypoxia

CONCLUSION
Rib fractures vary from being a minor injury that can be treated in outpatient’s bases, to a major injury that
can have life-threatening consequences. Accurate diagnosis, adequate analgesia and effective physiotherapy
are all essential components in the management of rib fractures if complications are to be avoided.

REFERENCES:
1. Brunett PH, et al. Pulmonary trauma. In: Tintinalli JE, et al. Tintinalli's Emergency Medicine: A
Comprehensive Study Guide. 7th ed. New York, N.Y.: The McGraw-Hill Companies; 2011.
2. Karlson KA. Rib fractures. [Link]
3. Fractures. The Merck Manuals: The Merck Manual for Healthcare Professionals.
[Link]
4. Preventing falls and related fractures. National Institute of Arthritis and Musculoskeletal and Skin
Diseases. [Link]