Broken Cracked Ribs
The chest cavity contains vital organs and is protected by a bony rib cage. The ribs are connected to each other by several layers of muscles which assist with breathing. They are also attached to the spine for added stability.
A rib fracture, simply put, is a break in the rib. Rib fractures that are single and non-displaced are classified as hairline fractures or simple fractures. Ribs usually fracture at the point of impact or in the back where structurally they are weakest. More complex fractures can cause the edges of the bone to become misaligned or displaced. A serious condition involved with rib fractures is called ‘flail chest’.
It occurs when multiple adjacent ribs are broken in multiple places, separating a segment which is free-floating and moves independently. The most common ribs fractured are the 7th through 10 th ribs. Fractures of the first and second ribs are rare but may be associated with serious damage to the brachial plexus of nerves, the subclavian vessels or associated with head, facial or thoracic aorta injuries.
A lower rib fracture is more likely associated with injuries to the diaphragm, liver or spleen. The most common mechanism causing rib fractures is blunt trauma (i.e. Automobile accidents, falls from height, assault, or even severe coughing). Blunt trauma causes rib fractures by exerting direct pressure on the rib causing it to break. Approximately 10% of all patients admitted for blunt chest trauma have one or more rib fractures.
Although the injury mechanism itself is an important consideration when discussing rib fractures; patient specific considerations are also important. Patients with advanced age, osteoporosis or osteopenia have an increased risk of number and severity of fractures. Rib fractures are typically diagnosed on chest x-ray and the severity of the fracture is easily seen.
Simple (non-displaced) fractures appear as cracks in the rib or a jagged edge. Displaced fractures appear to lack contour along the edge of the rib on x-ray. Floating segments of ribs, known as a flail chest, can also be easily seen on x-ray. Other imaging modalities such as CT scans also diagnose rib fractures and are more sensitive to identify them. CT scans are useful to determine if underlying lung injury is present, known as a contusion, or to identify if air has escaped the lung as a pneumothorax. The most common symptom of rib fractures is pain. Pain is typically elicited with breathing or coughing.
If the fractures are complex, the patient may suffer from additional damage to underlying structures. The sharp fractured end of the rib can puncture the lung, causing air leakage, a condition called a pneumothorax, which is potentially life threatening. In addition to pain, shortness of breath and decreased oxygen content in the blood can result from these injuries.
A flail chest is invariably accompanied by, a bruise of the lung tissue that can result in a clinical entity called acute lung injury. In its most severe form, acute lung injury can lead to a life threatening entity called adult respiratory distress syndrome (ARDS).
Respiratory failure is usually caused by the underlying pulmonary contusion but not by the anatomic flail chest itself. In addition, the flail segment moves in the opposite direction as the rest of the chest wall because of the ambient pressure in comparison to the pressure inside the lungs.
This so-called 'paradoxical motion' can increase the work and pain involved with breathing. There is no specific treatment for rib fractures, but various supportive measures can be taken.
Broken Vs Cracked Ribs
Simple rib fractures can be managed with pain management alone. Patients are encouraged to use an incentive spirometer, a used to help improve the function of, and control pain with medication as per their physician. If the pain is not relieved with medication alone other methods of pain relieve may be considered, eg. Nerve blockage. When patients sustain multiple rib fractures, oxygen support in addition to pain medication is sometimes required. A pneumothorax usually necessitates a procedure to drain the air out of the chest with a chest tube. A flail chest can significantly affect the mechanics of breathing and may require ventilatory support to improve blood oxygen concentration and possibly repair of the fractures with metal plates.
Authors: Jennifer A. Serfin, MD, W. Alan Guo, MD, PhD, FACS.
Transcript Dr. Miller: Surgical interventions for rib fractures. We're going to talk about that next on Scope Radio. Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr.
Tom Miller is on The Scope. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Thomas Varghese. He's a thoracic surgeon and works in the Department of Surgery here at the University of Utah.
Tom, tell us a little bit about when patients come to you for rib fractures, and is there a surgical treatment for that? Obviously, you can't cast a fractured rib, so when can you surgically intervene on a fractured rib? Varghese: It's a great question. One of the things that we really go down to get the detail about is the mechanism of the injury. Oftentimes rib fractures don't occur in isolation. They occur in conjunction with other types of injury.
It's one of the things that we have to really talk to patients about and try to differentiate it out. Is the injury only in the ribs, or is there associated nerve damage? Is there associated muscle damage or other bones affected? Because really, we can't just isolate and just treat the ribs without considering other damage that's occurred as a result of the injury. Miller: So a patient falls and is injured in a sports event, a sporting event. When might you look at that fracture and say, 'You know, it's not really going to heal without me going in there and repairing the rib?'
Varghese: The good thing is 85% of rib fractures heal on their own, and what we're really looking at is the alignment. With the fracture there, is the bone in alignment? And as long as the alignment is okay, giving those patients pain relief, a period of rest, rib fractures should heal by themselves.
Miller: That's a really good point. How long does it usually take for a rib to heal? That is, the patient will say, 'I'm having pain.'
What is it, two weeks, three weeks, six weeks? Varghese: It's usually, generally bone healing takes about four to six weeks. Miller: So they can expect to have some discomfort? Varghese: Some discomfort and some pain even afterwards. We first start thinking about surgical interventions after rib fractures, really after a two-month period of time.
Non-union is defined by after two to three months' period of time and the fracture is there, even if the alignment is correct and you don't see any evidence of healing, that's an indication for a surgical intervention. Miller: How about at the time of the injury? I mean, a fractured rib, the points of the bone could be sharp. Do they injure the lung at times? Varghese: They can.
And this is again going into the consideration that oftentimes rib fractures don't occur in isolation. So early indications are if you have something called flail chest which is multiple rib fractures really leading to a dissociation of a segment of the chest wall that impairs with your ability to breathe. Miller: How would that happen? An automobile accident, perhaps? Varghese: Automobile accidents, very bad skiing accidents, diving accidents. There's a variety of different mechanisms, and if you think about it, the ribs and the chest wall are really intended to absorb the force to protect everything on the inside and so it's doing its job. An analogy I often use with patients is if you think about a good bicycle helmet, you know a bicycle helmet is good because it absorbs the force and it cracks.
Ribs sort of do the same thing. The difference of course is a bicycle helmet you can throw away and buy a new one. You can't really do that with the ribs, and so you're kind of left with the damage as a result of the injury and then now you're literally trying to put. Miller: Well, obviously, the reason that football players wear these chest pads. Varghese: Absolutely. Miller: So they don't fracture their ribs.
The chest pads absorb the energy instead of their ribs. Varghese: Exactly. And so as a result the body tries to respond by trying to immobilize that area, and this is where we start running into problems. You can imagine if the ribs and the chest walls as a very dynamic instrument and so as you take a deep breath in and out, the chest expands in and out. When you have a rib fracture, your body tries to relatively isolate that area and as a result after rib fractures there are higher incidents of pneumonias. Miller: Because you're not breathing as deep, you're not getting rid of those secretions?
Varghese: Absolutely. And so this is again, it goes back to when we see a patient with a rib fracture you really have to think of the entire patient. You have to figure out where are the associated injuries, have they had pneumonias. You really have to do a comprehensive evaluation of that. Miller: So it sounds to me like a patient who would continue to have pain after about two months probably ought to talk to their physician about maybe giving them a referral to see a thoracic surgeon or yourself. Varghese: Somebody like myself.
Yeah, it's not just thoracic surgeons but probably thoracic surgeons that have experience taking care of thoracic trauma patients. It's sort of the consideration of what's going on with the patients. A lot of patients that I end up seeing I don't operate on with rib fractures, but even trying to figure out what's going on with the patient, making sure there aren't any other associated injuries, see if there are conservative mechanisms or non-surgical options to treat the patient to see if they can get better. And then if we can't, if there are certain key factors that we see that surgery will make a huge difference, those are the patients that we take to the operating room.
Miller: Would you also say that a patient with multiple rib fractures is more likely to need a surgical intervention, perhaps? Varghese: Yes. I would say multiple rib fractures. Miller: Flail chest. Miller: Flail chest, patients where the ribs are not aligned, like even early on if we see very bad fractures where the ribs are completely misaligned, you know that you can wait many weeks and many months, but if they're not in alignment they're not going to heal by themselves. Those are the patients that we often see early on.
Miller: Tom, what's your advice to a patient who has had a sporting injury, let's say they fall during water skiing or snow skiing or they're playing football, contact sports, and they come away with some pain in their ribs. Should they see a physician, should they get an x-ray, what would your advice be to them?
Varghese: My advice is don't try to tough it out. Go see somebody right away. If you have pain that lingers for a couple of hours after the event, and the next day, for example, you wake up and you're still sore and it's not getting any better, go ahead and see your doc. Miller: Any danger signs that you might ask them to look for? Varghese: I think that the danger signs you should look at are really in relation to the other types of injuries that could occur as a result of the rib fracture. For example, if the fractured segment goes and pokes an area of the lung, you could have a lung laceration.
What To Do For Broken Cracked Ribs
Those are patients where they'll have difficulty breathing, they could have lung collapse, they could start coughing up blood. All of those signs are indications that they should go see somebody right away.
Cracked Ribs Vs Broken Ribs
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