Rib fracture: causes, symptoms, diagnosis, treatment

ICD-10 code

S22 Fracture of rib(s), sternum and thoracic spine.

Epidemiology of rib fractures

Rib fractures account for 5 to 15% of all skeletal bone injuries.

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What causes rib fractures?

Rib fractures can occur with both direct and indirect mechanisms of injury. An example of the latter is compression of the chest in the anteroposterior direction, leading to a fracture of the ribs in the lateral sections. Significant displacements of the fragments, as a rule, do not occur, since the ribs are well connected to each other by a soft tissue case.

Anatomy of the ribs

The rib is classified as a long spongy bone. It consists of a bony part and a cartilaginous part located in front and connected to the sternum. The cartilages of the VIII-IX-X ribs do not reach the sternum, but are attached to the cartilage of the overlying rib. The XI-XII ribs do not reach the sternum and end in soft tissues. At the back, the ribs articulate with the vertebrae. Thus, a vertebra, two ribs and the sternum form a bone ring. The ribs are connected to each other by the external and internal intercostal muscles, and in the absence of ribs - by the membranes of the same name, the subcostal and transverse muscles of the chest. The skin, subcutaneous fat, superficial muscles, fascia and pleura complete the structure of the chest wall.

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Symptoms of a Rib Fracture

Complaints of severe pain at the site of injury, difficulty breathing - "impossible to inhale" are typical. Coughing causes the sharpest pain. The victims move, take off and put on clothes slowly, with fear of increasing pain. For the same reason, breathing becomes shallow. If the broken rib damages the lung, hemoptysis and subcutaneous emphysema are detected in the area of the fracture.

After the injury, the patient can immediately point out typical symptoms of a rib fracture: sharp chest pain, which tends to increase with breathing, movement, talking, coughing, and decreases at rest in a sitting position. Breathing is shallow, the chest on the side of the fracture lags behind when breathing.

Symptoms of rib fractures in the front and sides are difficult for patients to bear and are accompanied by breathing problems. Symptoms of rib fractures in the back are less pronounced and pulmonary ventilation problems are usually absent.

When several ribs are broken, the patient's condition worsens. Breathing is shallow. The pulse is rapid. The skin is pale, often bluish. The patient tries to sit still, avoiding the slightest movements. Symptoms of a rib fracture are characterized by swelling of soft tissues, bruises. Palpation reveals diffuse sharp pain, bone crepitus. If a rib fracture is accompanied by subcutaneous emphysema, palpation of the subcutaneous tissue reveals air crepitus, which, unlike bone crepitus, resembles a soft creaking.

The occurrence of pneumothorax is indicated by the deterioration of the patient's general condition and increasing dyspnea. Breathing on the affected side is not audible. Lung damage may be accompanied by hemoptysis.

Pneumothorax and hemothorax are complications that usually develop soon after the symptoms of a rib fracture. A few days after the fracture, another dangerous complication may develop - post-traumatic pneumonia. Elderly and senile patients are more prone to developing this complication, for whom pneumonia is particularly severe.

The development of pneumonia is indicated by a deterioration in the patient's general condition, symptoms of intoxication, difficulty breathing and an increase in temperature. It should be taken into account 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, only a deterioration in the general condition is noted.

The occurrence of post-traumatic pneumonia is caused by a decrease in the level of ventilation of the lungs on the side where there is a rib fracture. Breathing with a rib fracture is painful, so the patient tries to breathe as shallowly as possible.

Complications of rib fractures

The captivating simplicity of diagnosis, the satisfactory condition of the patient, and favorable treatment outcomes should not make the doctor feel complacent and oversimplified. Because a fracture of just one rib can be accompanied by the most serious complications: pneumothorax, rupture of the intercostal artery with internal bleeding (to stop which it is often necessary to perform a thoracotomy), injury and contusion of the lung and/or heart.

In case of a fracture of the lower ribs, damage to the abdominal organs (spleen, liver) and retroperitoneal space (kidneys) is possible. Therefore, auscultation and percussion of the chest, determination of pulse and blood pressure, blood and urine tests should be the minimum that will allow to avoid gross diagnostic errors.

It should be noted that if a single rib fracture can pose a threat to the patient's life, then multiple fractures increase it many times over. Multiple segmental, so-called final, or floating fractures are especially dangerous. They are always accompanied by acute respiratory failure and pleuropulmonary shock.

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How to recognize a rib fracture?

Anamnesis

Previous chest trauma.

Inspection and physical examination

There may be a lag in the chest in the act of breathing on the side of the injury. Sometimes a painful swelling is found in the area of the fracture.

When attempting to take a deep breath, pain occurs (in some cases, the pain is preceded by a click), as a result of which the chest excursion is interrupted - a positive symptom of "interrupted breath". This sign is not detected in chest contusions.

Another important clinical sign is the axial load symptom. It is checked by alternately compressing the chest in the sagittal and frontal planes. The chest is a bone ring, compression of some of its sections increases the load on others, therefore, when the ring is damaged, pain occurs not at the site of compression, but in the area of the bone defect (the symptom is considered positive).

Palpation reveals sharp local pain, crepitus is possible. A step-like deformation at the point of maximum pain also indicates a rib fracture.

To exclude possible complications, palpation of not only the chest, but also the abdominal cavity, auscultation, and determination of heart rate and blood pressure are performed.

A good aid in diagnostics is radiography. Unfortunately, due to a number of reasons (the shadow of dense internal organs, tangential layers, mismatch of the fracture line and the beam path), it is not always possible to recognize a rib fracture in standard settings. Additional studies are associated with technical difficulties, material costs and do not justify themselves. Therefore, the clinical picture plays a leading role in diagnosing rib fractures. If the diagnosis is not in doubt, in some cases it is possible to do without an X-ray examination.

To exclude complications, a general blood and urine test is prescribed.

Treatment of rib fractures

Indications for hospitalization

Rib fractures are treated conservatively. In a clinic or at home (under the supervision of a family doctor), it is possible to treat patients with a fracture of one, maximum two ribs, without complications and if the patient's condition is satisfactory. In other cases, the victim is hospitalized.

First aid for broken ribs

First aid for rib fractures begins with the administration of painkillers: 1 ml of a 2% solution of promedol. During transportation, the patient's chest is tightly bandaged. This method should not be used as a therapeutic immobilization (especially in the elderly) due to the risk of developing pneumonia.

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Drug treatment of rib fractures

An alcohol-procaine block is shown. 10 ml of 1-2% procaine solution is injected into the fracture site, after which, without removing the needle, 1 ml of 70% alcohol is added. If the block is performed correctly, the pain almost disappears, deep breathing and coughing become possible.

Prescribe metamizole sodium in tablets, expectorant mixture, mustard plasters on the chest, breathing exercises, UHF from the 3rd day after the injury. If the pain persists, the blockade can be repeated in 2-3 days.

Subsequently, electrophoresis of procaine and calcium chloride is applied to the fracture area, and therapeutic exercises are performed.

Approximate period of incapacity

Rib fractures heal in 3-4 weeks. Work capacity is restored in 4-5 weeks. If several ribs are broken, work can be resumed in 6-8 weeks.

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