Rib Fractures

• Typically due to blunt chest wall trauma, either high-energy in the young (e.g. RTC) or low-energy in the elderly (e.g. fall from standing)


• Less commonly they will arise from other trauma mechanisms
• Penetrating trauma
• Stress fracture e.g. chronic coughing
• Pathological fractures e.g. bone lesions
• Iatrogenic following chest radiotherapy
• NAI

• The most likely ribs to fracture are 4 - 10 as they are:
• Not protected by the clavicle like ribs 1 - 3
• Not free - floating as ribs 11 and 12 are
• They are most likely to fracture at their posterolateral curve


• The three main pathophysiological consequences of rib fractures are:
1. Pain-induced hypoventilation
2. Impaired gas exchange due to damaged lung parenchyma in the area underlying the rib fractures
3. Altered breathing mechanics

• Pain associated with rib movement reduces tidal volume
• Hypoventilation and atelectasis ensues
• Secretion retention and pneumonia (occurs in 1/3^rd of those >65yrs)

• Pulmonary contusion of the underlying lung causes oedema, varying degrees of haemorrhage and necrosis
• The damaged lung has poor compliance and is not well-ventilated, leading to intra-pulmonary shunt and decreased P_aO₂
• Consequences include:
• Increased work of breathing
• Hypoxia
• Pneumothorax or haemothorax
• ± need for invasive ventilation

• The presence of a flail segment causes paradoxical inwards-movement of the flail when negative intrapleural pressure is generated during inspiration
• Radiologically, a flail segment is three contiguous ribs fractured in ≥2 places
• Clinically, a flail chest is paradoxical chest wall movement in a patient who is breathing spontaneously
• The underlying lung does not expand, with reduced tidal volume
• There is some increase in respiratory rate to compensate, but overall there is hypoventilation
• Consequences include:
• Hypercapnoea
• ± need for NIV

• The most important determinants of morbidity and mortality are:
1. Number of ribs fractured
• ≥4 ribs fracture is associated with a higher mortality
• ≥7 ribs fractured carries a 29% mortality
• The presence of a flail segment carries a 33% mortality


2. Age
• The rate of pneumonia in the elderly patient with a rib fracture is ∽30%

• The Easter formula takes the above two factors into account, providing the Rib Fracture Score
• It is a useful screening tool to heighten awareness of increased risk, although it is not a well-validated predictor of requiring higher-level care

Rib Fracture Score = (total number of fractures in ribs x 1 unilateral / 2 bilateral) + age factor (0 - 4)

• Other scoring systems include:
• Chest Trauma Score
• RibScore
• Battle's Risk Prediction Score

• Humidifed oxygen, chest physiotherapy, incentive spirometry and nebulised saline are simple measures which will help
• Oxygen therapy may range from simple face masks through HFNO, NIV and ultimately I&V
• All of this risks being in vain if the patient is too sore to even breathe...

• Multi-modal, effective analgesia is key to improving outcomes and reducing pulmonary complications
• Simple analgesia in the form of paracetamol and, if not contraindicated, a NSAID is mandatory

• Initial management may require titration of IV morphine 0.1 - 0.2mg/kg
• Following this, a regular weak opioid should be prescribed (or strong opioid if weak opioid ineffective)
• + a strong opioid PRN for breakthrough pain and to facilitate mobilising, physiotherapy etc.
• An opioid PCA may be necessary instead of the above


• + regular laxatives
• + PRN anti-emetics
• ± gabapentinoids

• Thoracic epidurals allow better pulmonary function, leading to reduced incidence of pneumonia, number of ventilator days and mortality
• Interpleural block (suboptimal pain relief) and intercostal block (multiple injections and high risk intravascular injection/pneumothorax) are no longer in vogue

• Flail segment requiring NIV or I&V [only indication recommended by NICE; non-ventilated patients mayn't benefit (JAMA, 2022)]
• Symptomatic non-union
• Failure to wean from mechanical ventilation
• Severely displaced ribs found incidentally during procedure for other pathology

• Benefits greater if early (<3 days from injury) fixation vs. later fixation
• Fixation associated with reductions in:
• Incidence of pneumonia
• Opioid requirements
• Ventilatory days
• Need for tracheostomy
• LOS (critical care / hospital)
• Mortality (if early fixation)
• Incidence of chronic pain

• Standard pre-assessment
• Review of the mechanism of injury, any associated injuries and their management
• Degree of respiratory support inc. chest drains, pneumothoraces, surgical emphysema
• Investigations: standard bloods inc. G&XM, ECG, up-to-date chest imaging, TTE if suspected myocardial contusion

• Laterally positioned, though on occasion prone positioning required
• OLV with DLT/bronchial blocker

• Aim to extubate, especially if not ventilated prior to the procedure
• May require transfer back to higher care level post-operatively
• Post-operative analgesia mirrors pre-operative modalities, including LA infusion

• Prevalence of chronic pain varies; 22 - 67%
• It's predicted by the acute pain intensity only (not number or bilaterality of fractures)
• Operative fixation is associated with reduced incidence of chronic pain and greater return to work


• Prevalence of long-term disability is high, circa 33 - 50%
• It's predicted by both acute pain intensity and whether fractures were unilateral or bilateral