Rib fracture is a violation of the integrity of one or more ribs as a result of traumatic exposure. They are accompanied by intense chest pain, lead to limited mobility of the chest, for this reason, breathing becomes more shallow, which can cause a violation of pulmonary ventilation. Multiple rib fractures can be combined with damage to the chest organs and pose a danger to the patient’s life. The diagnosis of a rib fracture is made on the basis of radiography data, if necessary, ultrasound of the pleural cavity and its puncture are performed.
Rib fractures are the most common chest injury. Rib fractures account for about 16% of the total number of fractures. In elderly people, rib fractures are more common, which is due to an age-related decrease in the elasticity of the bone structures of the chest.
Uncomplicated fractures of one or two ribs fuse well and by themselves do not pose a threat to human life and health. The main danger with this injury is associated with respiratory disorders, damage to internal organs and the development of concomitant complications. Uncomplicated rib fractures occur in 40% of cases. The remaining 60% are accompanied by damage to the lungs, pleura and organs of the cardiovascular system. Multiple rib fractures are a serious injury that is dangerous both because of the possible development of pleuropulmonary shock and because of the sharply increasing likelihood of life–threatening complications.
Rib fracture causes
The cause of a rib fracture may be a fall, a direct blow to the ribs or compression of the chest. Most often, the ribs break at the place of the greatest bend – along the lateral surfaces of the chest. When one rib is fractured, the fragments are shifted very rarely. Multiple rib fractures are often accompanied by dislocation of fragments (fracture with displacement). In this case, fragments with their sharp ends can damage the pleura, lungs and intercostal vessels.
The chest is the upper part of the human torso. The bone frame that protects the heart and lungs is called the chest. The thorax is formed by 12 pairs of ribs. Intercostal muscles, vessels and nerves are located between the ribs. From behind, all the ribs connect to the spine. In its anterior part, ten pairs of upper ribs end in cartilage. Elastic rib cartilages provide chest mobility. The cartilages of the seven upper pairs of ribs connect to the sternum. The cartilages of the VIII-X ribs are connected to each other, and the XI and XII ribs lie freely, not articulating in the anterior part with other bone structures.
From the inside, the chest is lined with a connective tissue membrane (intra-thoracic fascia), immediately below the fascia is a pleura consisting of two smooth leaves. There is a thin layer of lubricant between the leaves, allowing the inner pleural leaf to slide freely relative to the outer one when breathing. Lung tissue is formed by the smallest hollow bubbles – alveoli, in which, in fact, gas exchange takes place.
Damage to the pleura and lungs is often accompanied by the development of complications – hemothorax and pneumothorax. With hemothorax, blood accumulates between the outer and inner pleural leaves. With pneumothorax, air accumulates in the chest. The lung is compressed, decreases in volume, the alveoli subside and cease to take part in breathing. Rib fracture with lung damage may be accompanied by air penetration into the subcutaneous tissue (subcutaneous emphysema). If the intercostal vessels are damaged, profuse bleeding into the pleural cavity or soft tissues may develop.
Rib fracture symptoms
The patient complains of a sharp pain in the chest. The pain increases with breathing, movements, talking, coughing, decreases at rest in a sitting position. Breathing is shallow, the chest on the affected side lags behind when breathing. Palpation of a broken rib reveals a site of sharp soreness, sometimes bone crepitation (a kind of crunch of bone fragments).
Anterior and lateral rib fractures are hard to bear by patients, accompanied by respiratory disorders. When the posterior parts of the ribs are damaged, the violation of pulmonary ventilation is usually less pronounced. With multiple fractures of the ribs, the patient’s condition worsens. Breathing is shallow. The pulse is rapid. The skin is pale, often cyanotic. The patient tries to sit still, avoids the slightest movements.
In the area of fractures, there is swelling of soft tissues, bruising. When palpation is determined by spilled sharp soreness, bone crepitation. If a rib fracture is accompanied by subcutaneous emphysema, palpation of subcutaneous tissue reveals air crepitation, which, unlike bone crepitation, resembles a soft creaking.
The occurrence of pneumothorax is indicated by the deterioration of the general condition of the patient, increasing shortness of breath. Breathing on the affected side is not monitored. Lung damage may be accompanied by hemoptysis. Pneumothorax and hemothorax are complications that, as a rule, develop in the near future after injury. A few days after the fracture, another dangerous complication may develop – post-traumatic pneumonia. Elderly and senile patients, in whom pneumonia is particularly severe, are more likely to develop this complication.
The formation of pneumonia is indicated by the deterioration of the general condition, symptoms of intoxication, difficulty breathing and fever. It should be borne in mind that in weakened elderly patients and patients with severe combined trauma, post-traumatic pneumonia is not always accompanied by an increase in temperature. In some cases, there is only a deterioration in the general condition.
The occurrence of post-traumatic pneumonia is caused by a decrease in the level of lung ventilation on the side of the fracture. Breathing with a rib fracture is painful, so the patient tries to breathe as superficially as possible. The problem is aggravated by self-medication. Many believe that for a good fusion of the ribs, it is necessary to limit their mobility by bandaging the chest. As a result, breathing is restricted even more, congestion appears in the lungs, and congestive pneumonia develops.
In case of rib fracture, fixation is not required in the absolute majority of cases. The exception is some complicated and multiple rib fractures, for which help should be provided only in a hospital setting. In the absence of timely treatment, complications of rib fractures pose an immediate danger to the patient’s life. In order to prevent the development of complications or eliminate their consequences, if a rib fracture is suspected, it is necessary to seek qualified medical help as soon as possible.
The diagnosis of a rib fracture and concomitant complications is established by a traumatologist on the basis of an X-ray examination. If pneumothorax and hemothorax are suspected, an ultrasound of the pleural cavity, a lung X-ray, and a pleural puncture are additionally performed.
Rib fracture treatment
Uncomplicated injuries of one (in some cases, two) ribs are treated on an outpatient basis. A fracture of three or more ribs is an indication for emergency hospitalization in the department of traumatology and orthopedics. In case of uncomplicated rib fracture at the time of admission, the traumatologist performs local anesthesia of the fracture or vago-sympathetic blockade according to Vishnevsky. Then the patient is prescribed analgesics, expectorants, physiotherapy procedures and therapeutic gymnastics to improve lung ventilation.
Sometimes pneumothorax and hemothorax develop not at the time of admission of the patient, but somewhat later. During the treatment of complicated rib fractures, along with standard procedures (fracture anesthesia, analgesics, physiotherapy and therapeutic gymnastics), additional therapeutic measures are carried out. A small amount of blood in the cavity between the pleural leaves resolves independently. With a pronounced hemothorax, a puncture of the pleural cavity is performed. The doctor, under local anesthesia, inserts a special needle into the pleural cavity and removes the accumulated blood. Sometimes the hemothorax develops repeatedly, so several punctures have to be performed during treatment.
With pneumothorax, in some cases, it is enough to perform a puncture to remove air. A strained pneumothorax is an indication for urgent drainage of the pleural cavity. Under local anesthesia, the doctor makes a small incision in the second intercostal space along the midclavicular line. A drainage tube is inserted into the incision. The other end of the tube is lowered into a jar of liquid. It is important that this jar is always below the level of the patient’s chest. The air accumulating in the pleural cavity exits through the tube, the lung straightens. Pleural drainage is usually maintained for several days until air ceases to flow through the drainage tube. Then a control X-ray is performed and the drainage is removed.
During the treatment of post-traumatic pneumonia, along with general therapeutic measures (antibiotics, physiotherapy), it is very important to carry out therapeutic exercises to restore normal ventilation of the lungs. Fixation of rib fractures is required very rarely and is carried out, as a rule, with massive chest injuries accompanied by multiple unstable rib fractures.
Prognosis and prevention
The prognosis for single uncomplicated rib fractures is favorable. The outcome of multiple injuries, especially complicated ones, depends on the timeliness of the start and adequacy of therapeutic measures. The average period of disability for uncomplicated injuries is about 1 month. The duration of treatment of multiple and complicated fractures is determined by the severity of complications and the general condition of the patient. Primary prevention consists in carrying out measures to reduce injuries. A decrease in the likelihood of complications is noted with immediate access to a traumatologist and early initiation of treatment.