A patient with an isolated rib fracture or a
minor costochondral separation usually has a
history of falling on the side of the chest, being struck by a blunt object, coughing violently or leaning over a rigid edge.
The initial chest pain may subside, but over the
next few hours or days pain
increases with movement, interfering with sleep and activity and
becoming severe with coughing or deep inspiration.
The patient is often worried about having a broken
rib, and may have a sensation of bony crepitus or abnormal rib movement. Breath sounds bilaterally should be normal unless
there is substantial splinting or a pneumothorax
or hemothorax is present. There is point
tenderness over the site of the injury and
occasionally bony crepitance can be felt.
What to do:
Examine the patient for possible associated
injuries; e.g., do an abdominal exam to look for
any signs of a splenic or hepatic injury. If there was a significan mechanism of injury, the patietn may require a comprenhensive evaluation to rule out life and limb threatening injuries.
When there is a history of minor trauma, check for pain with indirect stress on the
suspected fracture site. Compress the rib
medially if a posterior or anterior fracture is
suspected. Compress the rib
anteriorly/posteriorly if a fracture is
suspected at a lateral location. When pain
occurs at the suspected fracture site with
indirect stress, this is clinical evidence of a
fracture or separation and should be so
documented on the chart.
Obtain any history of chronic pulmonary problems
or heavy smoking.
Unless the patient is elderly or has pulmonary
disease, have him try out a rib belt during his
wait for x rays.
Send the patient for a PA & lateral chest x ray
to rule out a pneumothorax, hemothorax, evidence
of pulmonary contusion, etc. Additional oblique rib films
for radiological documentation of a fracture are
optional and often unproductive, but these films are indicated when there is a suspicion of multiple rib fractures, especially in the elderly.
If there is no suspicion of underlying injury and when there is clinical or radiologic evidence of a rib fracture or chondral separation:
Provide a potent oral analgesic (Motrin, Aleve,
Tylenol with codeine, Lorcet, Percocet).
Instruct the patient on the intermittent use
of an elastic and velcro rib belt if it reduces
pain. Place the top of the belt at the inferior tip of the xyphoid process, tightening it around the chest enough to obtain maximum pain relief. the fib belt may be left on almost continuously for the first one to four days but it should be removed as comfort allows thereafter.
Instruct the patient on the importance of
deep breathing and coughing (without the rib belt but using a pillow
splint) to help prevent pneumonia. Tell him to
take enough pain medicine to allow coughing and
Provide the patient with an appropriate work
excuse and refer him for followup care in 48 hours. Tell him
to expect gradually decreasing discomfort for
about two weeks, and forbid strenuous activity
for approximately eight weeks.
Severe worsening of chest pain, shortness of breath, fever or purulent sputum may signal pulmonary complications and should prompt a return visit. A greater incidence of complications can be expected in patients with displaced rib fractures.
When patients are elderly or have pulmonary or cardiac compromise, or multiple fractures or other injuries which might compromise respiratory dynamics, consider hospitalization for observation, pain control and pulmonary toilet. Blood gases and pulmonary function tests can aid in evaluation of breathing.
When there is no clinical or radiologic evidence of a fracture, treat the pain as you would any other contusion, using an appropriate analgesic.
What not to do:
Do not confuse simple rib fractures with massive
blunt trauma to the chest. The evaluation and
management is quite different.
Do not tape ribs or use continuous strapping. This will lead to
an atelectatic lung prone to pneumonia.
Do not assume there is no fracture just because
the x rays are negative. Rib fractures are often
not apparent on x ray, especially when they
occur in the cartilagenous portion of the rib.
The patient deserves the disability period and
analgesics commensurate with the real injury.
Most fractures and separations are treated with
immobilization, but ribs are a special problem
because patients have to continue breathing. In
the presence of severe pain one should consider
the use of an intercostal nerve block or injection
of the fracture hematoma with 0.5% bupivacaine
hydrochloride (Marcaine). Because of the risks of
pneumothorax or hemothorax, this procedure, in
most cases, should be reserved for secondary
management when initial treatment has proven
Quick G: A randomized clinical trial of rib belts for simple fractures. Am J Emerg Med 1990;8:277-281.
Lazcano A, Dougherty J, Kruger M: Use of rib belts in acute rib fractures Am J Emerg Med 1989;7:97-100.