Initial evaluation and management of rib fractures

INTRODUCTION — Rib fractures are common injuries that occur most often following blunt thoracic trauma but can also result from severe coughing, athletic activities (eg, rowing, swinging golf clubs, throwing), and nonaccidental trauma (ie, child abuse). Concomitant injuries and complications range from mild discomfort to life-threatening conditions such as pneumothorax, splenic laceration, and pneumonia.

This topic will review the initial evaluation and management of isolated rib fractures (including stress fractures) not involving intrathoracic injury. Discussions of the inpatient management of multiple rib fractures, blunt and penetrating thoracic trauma, and stress fractures generally are found separately:

●(See "Initial management of trauma in adults".)

●(See "Initial evaluation and management of chest wall trauma in adults".)

●(See "Initial evaluation and management of blunt thoracic trauma in adults".)

●(See "Thoracic trauma in children: Initial stabilization and evaluation".)

●(See "Initial evaluation and management of penetrating thoracic trauma in adults".)

●(See "Inpatient management of traumatic rib fractures and flail chest in adults".)

●(See "Surgical management of severe rib fractures".)

●(See "Overview of stress fractures".)

ANATOMY AND MECHANISMS OF INJURY

Anatomy — The chest wall consists of 12 pairs of ribs, the first seven of which articulate both posteriorly with the spine and anteriorly with the sternum (figure 1 and figure 2). Ribs 8 to 10 attach anteriorly to the costal cartilage. The lowest two ribs are "floating" and do not connect anteriorly [1]. The neurovascular bundle travels below each rib and includes the intercostal vein, artery, and nerve.

The first rib is unique in that the scaleni insert onto it, and it therefore is exposed to stresses from the action of these neck muscles. The superior ribs (numbers 1 to 3) are protected by the scapula, clavicle, and soft tissue, while the inferior "floating" ribs are relatively mobile. Therefore, the more vulnerable middle ribs (numbers 4 to 10) are most susceptible to injury from blunt trauma. Fractures of superior ribs reflect trauma involving significant force and the potential for injury to major vessels and lung parenchyma.

Both displaced and nondisplaced fractures can be seen in adults and children [2]. Due to the greater pliability of children's ribs, greater force is required to produce a fracture.

Mechanisms of injury

●General mechanisms – Most rib fractures are caused by direct trauma to the chest wall. This can occur from blunt (eg, motor vehicle collision) or penetrating (eg, gunshot) trauma. A single blow may cause rib fractures in multiple places. Traumatic fractures most often occur at the site of impact or the posterolateral bend, where the rib is weakest. (See "Initial evaluation and management of chest wall trauma in adults".)

●Pathologic fractures due to metastases – Cancers that metastasize to bone (eg, prostate, breast, renal) frequently become apparent in a rib and cause pathologic fractures. Ribs are relatively thin compared with major long bones and are more likely to fracture when invaded by a metastatic lesion. (See "Epidemiology, clinical presentation, and diagnosis of bone metastasis in adults".)

●Stress fractures – Ribs can sustain stress fractures from repetitive minor trauma [3-5]. Stress fractures may be seen in patients with a chronic cough [6,7] and in athletes, particularly rowers, golfers, throwers, and others [5,8-13]. The first rib is susceptible to stress fractures in throwing athletes due to the unique forces exerted during the throwing motion [8,14]. (See "Overview of stress fractures".)

●Nonaccidental trauma in infants – In the absence of significant trauma (eg, motor vehicle collision), rib fractures in infants are extremely uncommon. Possible nonaccidental trauma (ie, child abuse) must be investigated when such fractures are discovered. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Thoracic injury'.)

CLINICAL FEATURES

History

Sudden pain with known trauma — Patients with rib fractures typically describe a history of blunt trauma to the chest wall. They can often localize the pain to one or two ribs, and they describe an injury that corresponds with the area of discomfort. Deep breaths, coughing, movements of chest, and sneezing frequently reproduce or exacerbate the pain.

Gradual pain with minimal trauma — Rib stress fractures present with a gradual onset of activity-related chest wall pain, similar to stress fractures of other bones [11,15-17]. The pain often first occurs only with the inciting activity (eg, coughing, rowing, swinging a golf club, throwing) then progresses to pain with deep breathing, sneezing, laughing, or simple movements such as rolling over in bed or reaching overhead.

History unavailable — In patients with impaired consciousness (eg, victims of high-energy trauma) who are unable to localize pain to the chest wall, rib fractures are identified by careful examination of the chest wall and back as well as imaging. In most victims of major trauma, multiple or displaced rib fractures are identified on the routine chest radiograph (CXR) obtained during the initial trauma evaluation [18]. Obtaining a supine anteroposterior CXR is common practice in all major trauma victims. The goal of the initial trauma CXR is to identify associated injuries that may require urgent intervention (eg, hemothorax or pneumothorax) rather than rib fractures.(See "Initial evaluation and management of blunt thoracic trauma in adults".)

Examination — Signs of rib fractures include point tenderness on a specific rib or focal tenderness caused by compression of the ribcage distant from the site of pain. Bony crepitus and ecchymosis may be present. Bony crepitus is an auscultated click caused by movement of the rib fracture and can be heard with a stethoscope placed over the fracture site.

Clinicians should examine for associated injuries in patients with suspected rib fractures. Diminished breath sounds may reflect splinting from the pain of a rib fracture or chest wall contusion but may also reflect the presence of a significant injury (eg, pneumothorax, hemothorax, or pulmonary contusion). Findings other than diminished breath sounds suggestive of significant injury include the following (see "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Pulmonary injury' and "Initial evaluation and management of chest wall trauma in adults", section on 'Flail chest'):

●Chest wall crepitus from subcutaneous emphysema suggests pneumothorax or tracheobronchial injury

●Crackles or rales suggests pulmonary contusion

●Chest wall segment that exhibits paradoxical motion (ie, moves in the opposite direction of uninjured, normal-functioning chest wall) suggests a flail chest, which occurs when three or more adjacent ribs are each fractured in two places (figure 3 and figure 4)

●Abdominal tenderness when lower rib fractures (ribs 9 through 12) are suspected suggests intra-abdominal injury

DIAGNOSIS — A clinical diagnosis of isolated rib fractures can be made in a patient with rib point tenderness, particularly with a history of trauma. A definitive diagnosis of rib fractures can be made with advanced imaging (ie, computed tomography [CT] scan), but advanced imaging is often not necessary for isolated (one or two ribs) fractures once associated injury has been adequately excluded, typically with a chest radiograph (CXR).

FRACTURE PATTERNS ASSOCIATED WITH INTERNAL INJURIES — Multiple rib fractures (≥3) or fractures in the upper or lower rib cage are associated with internal injuries such as liver or spleen lacerations, mediastinal injury, pneumothorax, hemothorax, flail chest, and pulmonary contusions. These fractures are sustained by patients as a result of more serious trauma. Associated injuries are unlikely to occur with isolated rib fractures or minor trauma.

Intrathoracic injury, such as pneumothorax or pulmonary contusion, can occur in association with rib fractures at any level. The risk of intra-abdominal or intrathoracic injury increases if two or more rib fractures are present at the same level [19-22]. Some specific rib fracture patterns and associated injuries include the following:

●Ribs 9 through 12 may be associated with intra-abdominal injury. (See "Initial evaluation and management of blunt abdominal trauma in adults", section on 'Evaluation and management'.)

●Ribs 1, 2, or 3 may be associated with mediastinal injury, particularly to the aorta, and are associated with increased mortality in some observational studies [23]. Specifically, first rib fractures are associated with greater overall injury severity and life-threatening internal injury (including injuries to the brain, spine, lungs, and pelvis) independent of mechanism, age, or sex [24]. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Specific injuries'.)

●Right lower ribs may be associated with hepatic injury. (See "Management of hepatic trauma in adults", section on 'History and physical examination'.)

●Left lower ribs may be associated with splenic injury. In the setting of blunt trauma, splenic injuries typically have significant additional injuries and not isolated rib fractures. (See "Management of splenic injury in the adult trauma patient", section on 'History and physical examination'.)

●The posterior portion of the lower ribs is often associated with renal injury. (See "Management of blunt and penetrating renal trauma", section on 'History and physical'.)

●Three or more adjacent ribs each fractured in two places (ie, flail chest) (figure 4) is often associated with significant morbidity from pulmonary contusion as well as injuries elsewhere. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Flail chest'.)

DIAGNOSTIC EVALUATION

Chest radiographs (all patients) — In patients with suspected rib fractures or chest wall trauma, chest radiographs (CXRs) are obtained primarily to rule out associated injuries (eg, pneumothorax, hemothorax) with a secondary goal of confirming the presence of rib fractures. Standard posterior-anterior (PA) and lateral CXRs can identify some rib fractures, but overall sensitivity is poor (image 1 and image 2) [18,23,25]. CXR usually underestimates the number of rib fractures and may not detect nondisplaced fractures. In patients who cannot undergo a PA and lateral radiograph (eg, those with hemodynamic instability or spinal immobilization), an anteroposterior (AP) radiograph can be obtained (image 3), as can bedside ultrasound. The initial screening CXR obtained in trauma patients remains a useful tool, and injuries of sufficient magnitude to appear on CXR may predict subsequent pulmonary morbidity more accurately than chest computed tomography (CT) [26].

Candidates for additional imaging — Even though isolated rib fractures can be a clinical diagnosis, confirming or excluding the presence of rib fractures may be warranted in certain circumstances such as the following:

●Older patients with tenderness over three or more ribs since presence of multiple fractures may change disposition. Older patients have significantly increased morbidity from multiple rib fractures and are more likely to have pathologic fractures (eg, from metastatic lesions) [27-29]. (See "Geriatric trauma: Initial evaluation and management".)

●Patients with significant respiratory splinting or hypoxia.

●Athletes in whom stress fracture is a concern and would limit activity or affect returning to competition.

●Patients in whom the location of suspected rib fractures increases risk of associated intra-abdominal or intrathoracic injury. For example, rib fractures of the lower rib cage can be associated with intra-abdominal injury, and abdominal CT may be useful [30]. (See 'Fracture patterns associated with internal injuries' above.)

●Infants rarely have rib fractures in the absence of significant trauma (eg, motor vehicle collision); therefore, possible nonaccidental trauma (ie, child abuse) must be investigated in these patients. A skeletal survey should be obtained since the presence of multiple fractures in various stages of healing is consistent with abuse. Further evaluation and management of possible child abuse is discussed separately. (See "Physical child abuse: Diagnostic evaluation and management".)

Choice of supplemental imaging — In most cases when CXR is not sufficient for the identification of traumatic rib fractures, chest CT should be performed next. When expertise and equipment are available, emergency physician-performed bedside ultrasound is an emerging modality with test characteristics comparable to CT for identifying rib fractures. In patients with concern for stress fracture in whom definitive diagnosis will change management, magnetic resonance imaging (MRI) has become the modality of choice. Both bone scintigraphy and MRI have traditionally had better sensitivity for stress fracture than CT but are limited by resource availability. Rib radiographs have very limited utility when CT is available. (See "Overview of stress fractures", section on 'Approach to stress fracture imaging' and "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Rib and sternal injury'.)

Chest computed tomography — Chest CT is highly accurate for showing the location and number of rib fractures (image 4). CT should not be performed for the sole purpose of assessing potential isolated rib fractures. Rib fractures are commonly identified on CT studies obtained in trauma patients since CT is invaluable for identifying intrathoracic injuries. CT can provide additional insight into the characteristics of severely displaced fractures and therefore may be useful for operative planning (image 5).

CT demonstrates greater sensitivity and specificity for rib fractures compared with plain radiographs. Observational studies of trauma patients show a clear increase in the number of rib fractures identified on chest CT compared with CXR, but the clinical significance of these additional findings is generally minimal [25,31,32]. As examples, a retrospective study of 330 older patients with ground-level falls found patients with rib fractures identified on CT but not CXR had no increased need for procedural intervention, worse mortality, or longer hospital length of stay [32]. In a retrospective study of 399 patients with rib fractures who had both CXR and chest CT, one-third of patients with three or more rib fractures identified only on CT had a change in management but without improvement in pulmonary outcomes or mortality [25]. In a retrospective study of 589 patients with blunt trauma and a normal CXR, chest CT identified 66 rib fractures not seen on the radiograph but only 12 injuries (mostly pneumothorax) that the authors defined a priori as having major clinical significance [31]. Chest CT imaging of chest wall trauma is discussed in detail elsewhere. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Chest computed tomography for most patients' and "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Chest imaging'.)

Rib radiographs — Rib radiographs (sometimes referred to as a "rib series") have limited utility and should only be obtained if there is high clinical suspicion for pathologic or multiple rib fractures not apparent on CXR, detection of additional fractures would alter management, and CT is not available. Rib series have higher sensitivity for rib fractures compared with CXR because they use a bone exposure (which entails higher levels of radiation) and include oblique views of the chest wall. However, in most cases, clinical findings and CXR are sufficient for management decisions, and a rib series is unnecessary [33-36]. A rib series is rarely obtained in trauma patients since CT has become the standard imaging modality and can accurately identify rib fractures.

Bedside ultrasound — Emergency physician-performed bedside ultrasound is both sensitive and specific for identifying rib fractures. Ultrasound may be more sensitive than CXR in identifying nondisplaced rib fractures and is increasingly being used as a method for diagnosing rib stress fractures [37]. However, similar to other ultrasound indications, bedside ultrasound performance is dependent on operator experience. The use of ultrasound for diagnosis of rib fractures is reviewed separately. (See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Rib and sternal injury'.) [27-30]

Magnetic resonance imaging — MRI is the imaging modality of choice for many other types of stress fractures. The oblique orientation of the ribs and the difficulty with numbering them on axial or coronal scanning can make MRI difficult to interpret; thus, detailed ordering or discussion with the radiologist is important to ensure use of an appropriate protocol (ie, thin sections of the area of concern). MRI is the most expensive imaging modality, and the detailed soft tissue images are of lesser importance when evaluating for fractures. (See "Overview of stress fractures", section on 'Magnetic resonance imaging'.)

Bone scintigraphy — Bone scintigraphy (ie, bone scan) of the chest wall has traditionally been the preferred instrument to diagnose rib stress fractures early in the pathologic process due to its high sensitivity and ease of interpretation (image 6) [4,16,17]. Such fractures typically are not visible on CXR until late in their healing, when visible callus is present. However, MRI has supplanted bone scintigraphy, which requires large doses of ionizing radiation and has poor specificity. (See "Overview of stress fractures", section on 'Bone scan'.)

WHICH OUTPATIENTS SHOULD BE REFERRED TO THE EMERGENCY DEPARTMENT — The following patients who have rib fractures identified on an outpatient radiograph should be referred to the emergency department for further evaluation:

●Superior rib fractures (first or second rib)

●Three or more rib fractures

●Concern for associated internal injuries (eg, abdominal pain, trouble breathing, hematuria)

●Age greater than 65 or frailty

INITIAL MANAGEMENT

Analgesia and pulmonary hygiene — The cornerstone of rib fracture management is pain control once significant associated injuries have been evaluated and treated [38-40].

●Early and adequate pain relief helps avoid pulmonary complications (eg, pneumonia) from splinting and atelectasis. The choice of analgesia depends upon the injury, the clinician's comfort performing nerve blocks, and the ease with which more invasive treatments can be performed. Analgesia for isolated rib fractures (ie, one or two ribs) includes nonsteroidal antiinflammatory drugs (NSAIDs) with or without opioids [41].

Good outcomes have been described from emergency physician-performed serratus anterior plane blocks, erector spinae plane blocks, and rhomboid intercostal sub-serratus blocks [42-46]. Nerve blocks can provide analgesia while minimizing opioid use, which may especially benefit older adults who have increased sensitivity to the adverse effects of opioids. Serratus anterior plane blocks are generally effective for anterior and lateral fractures of the second through ninth ribs. Local anesthetic injection is usually performed at the fifth rib level; the procedure is discussed in detail separately. (See "Thoracic nerve block techniques", section on 'Serratus plane block'.)

●Instruct patients to use an incentive spirometer intermittently throughout the day after analgesics have taken effect. Holding a pillow or similar soft brace against the fracture site reduces discomfort while using the spirometer or when coughing or sneezing. Lung volume expansion treatments (ie, incentive spirometry, deep breathing, and coughing) reduce secretions and prevent atelectasis and other complications [40,47]. We recommend not using rib belts or binders because they may compromise respiratory function [48,49].

●Patients with more severe injuries, particularly if ventilation is compromised, may need admission and invasive treatments as well as pulmonary support. Regional anesthesia techniques available for the management of multiple rib fractures include continuous epidural infusion, paravertebral block, intrapleural infusion, and intercostal nerve block (figure 5). Analgesia for severe and multiple rib fractures in admitted patients is discussed separately. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Pain control'.)

Tracheal intubation should be avoided in the absence of respiratory failure. A trial of noninvasive positive pressure ventilation is warranted in alert patients with marginal respiratory status to avoid obligatory mechanical ventilation [50]. Pulmonary support in admitted patients with rib fractures is discussed separately. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Supportive care'.)

Treatment of stress fractures — In general, rib stress fractures are treated similarly to other low-risk stress fractures with activity limitation even though high-quality evidence is scarce [51]. (See 'Return to sports and work' below and "Overview of stress fractures".)

Delayed complications — The rate of significant complications associated with rib fractures increases with the number and severity (eg, displacement) of fractures, patient age or frailty, and compromised respiratory function, either acute or chronic due to underlying disease. Among older adults, morbidity and mortality are twice that in younger populations, and some increased morbidity is apparent in patients over 45 years old.

●Pneumonia is one of the most common complications of rib fractures, typically due to splinting and atelectasis, and risk correlates with number of fractured ribs and patient's age. Retained hemothorax, pulmonary effusion, aspiration, empyema, and acute respiratory distress syndrome can also occur. These are discussed in greater detail elsewhere. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Rib fracture morbidity'.)

●Delayed pneumothorax can occur but is rare with minor injuries [52].

●Rib fractures rarely go on to nonunion, and not all nonunions require surgery. Surgical fixation may be of benefit with some types of rib fractures, particularly those associated with chest wall deformity, flail chest, or symptomatic nonunion. The appropriate role of surgical fixation is discussed separately. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Surgical management'.)

●Displaced rib fractures increase the risk of injury to the lung and proximate intercostal blood vessels [53,54]. Case reports indicate that delayed bleeding from intercostal vessels or other injuries can be life threatening, particularly in older patients [55-57]. (See "Geriatric trauma: Initial evaluation and management", section on 'Chest trauma'.)

Indications for surgical consultation — In general, surgical consultation is indicated in patients with significant chest wall deformity, flail chest, multiple severely displaced rib fractures, and developing respiratory failure despite medical management. Surgical options exist for rib stabilization, and if performed within 72 hours of injury, can decrease rates of mechanical ventilation, pneumonia, and tracheostomy in the appropriate candidates [58]. Indications for surgery and options for surgical rib stabilization are discussed in detail elsewhere. (See "Surgical management of severe rib fractures".)

Disposition — An algorithm to assist with the disposition of patients with isolated rib fractures is provided (algorithm 1). Rib fracture-associated morbidity and mortality, interventions required for adequate pain control, and additional needed treatments can vary substantially. Therefore, we suggest that institutions develop clear guidelines for the management and disposition of patients with rib fractures to help ensure proper care. Patients who received treatment consistent with best-practice guidelines at United States trauma centers were found to have decreased mortality [59]. The appropriate disposition of patients with isolated rib fractures is based largely on retrospective observational studies, and thus, published guidelines rely heavily on clinical experience and expert opinion [21,40,53,60].

●Potentially seriously ill patients – Depending upon the number of rib fractures, the nature and severity of associated injuries, and the nature of medical comorbidities, the patient may be cared for in a monitored unit or an intensive care unit (ICU).

A patient with severe rib fractures (eg, >5 ribs involved, multiple displaced fractures, flail chest) or signs of significant respiratory compromise, or in whom there is concern for developing respiratory compromise, should be admitted to the ICU. No universally accepted definition of "severe rib fracture" exists. An increasing number of fractures and greater fracture complexity (eg, comminution, displacement) increases the risk of complications, but other factors (eg, comorbidities such as frailty, chronic obstructive pulmonary disease [COPD], neuromuscular disease) may be considered. Signs of respiratory compromise include severe tachypnea, pulse oximetry <92 percent breathing room air, accessory muscle use, and splinting respirations.

Most older adults admitted with isolated rib fractures do not need ICU admission. In a large, retrospective study of just over 5000 patients 65 years of age or older, only 1 percent out of 3577 patients with two or more rib fractures initially triaged to a regular floor bed developed complications requiring intubation or transfer to an intensive care setting [61]. Complications were more common in patients with chronic kidney insufficiency, traumatic pneumothorax, concurrent sternal fracture, substance use disorder, or oxygen saturation below 95 percent while in the emergency department.

●Patients with three or more rib fractures – In many cases, we hospitalize patients with three or more rib fractures given the association with increased morbidity and mortality. A patient with tachypnea (ie, rate >18 breaths per minute), mild hypoxia (pulse oximetry ≤95 percent breathing room air), or an incentive spirometry volume <1 L should be admitted. Spirometry measurements (ie, incentive spirometry volume, forced vital capacity, forced expiratory volume in one second, and negative inspiratory force) have also been shown to correlate with pulmonary complications in patients with multiple rib fractures [62-69]. Several scoring systems to guide disposition of patients with multiple rib fractures have been developed, but none are universally accepted [20,62,63,70-72]. The risk of complications varies widely among individual patients. Patients with multiple rib fractures sustained from high-energy trauma are best managed at a trauma center.

Patients with three (or possibly more) rib fractures may be discharged if they are generally healthy and have good respiratory mechanics (algorithm 1). Older patients are at increased risk of complications from rib fractures, but there is no specific age threshold for admission, and patient frailty and pulmonary reserve is likely more important than age. Clinical judgment is important. Patients should ideally have all of the following in order to be discharged:

•Not frail or generally deconditioned  

•No pulmonary comorbidities such as COPD, asthma, or active smoking

•Rib fractures are unilateral

•Pain is controlled with oral medications

•Low risk of significant internal injury or injury has been ruled out with imaging

•Social circumstances and supports are acceptable

●Patients with one or two rib fractures – Patients with one or two nondisplaced rib fractures identified on imaging studies, or focal tenderness over one or two ribs but no visualized fracture on CXR (thus are assumed to have a rib fracture), and at low risk for other injuries may be treated with analgesics and discharged without a period of observation. They should be instructed to arrange follow-up care and to seek immediate medical evaluation for any concerning symptoms, such as shortness of breath, new or increasing pain, worsening cough, generalized weakness, pallor, or fever.

A lower threshold for hospitalization and possible admission to an intensive care setting, even for a single rib fracture, is appropriate in higher-risk patients (algorithm 1) [40].

●Outpatient care – We provide discharged patients with an incentive spirometer, educate in its proper use, and strongly encourage frequent use to prevent atelectasis and pneumonia. Secondary injuries due to rib fractures (eg, pneumothorax, hemothorax) can infrequently develop hours to days after the injury [54,55,73-75]. All discharged patients must be given precise instructions regarding symptoms that should prompt seeking immediate medical care, such as difficulty breathing, new or severe pain, worsening cough, generalized weakness, pallor, or fever.

FOLLOW-UP CARE — Follow-up with the patient's primary care physician six to eight weeks after the injury to assess for persistent pain, abnormal lung auscultation, or hypoxia is reasonable. Routine follow-up chest radiographs (CXRs) obtained days after the injury are not recommended since they do not add new information to a careful clinical examination; they should be performed only if indicated by clinical findings (eg, unilateral decreased breath sounds suggesting pneumothorax, persistent pain suggesting malunion or nonunion) [76].

Most nonpathologic rib fractures heal within six weeks. Many patients are able to resume daily activities much sooner. However, patients should be warned that pain from rib fractures can be severe for several days following the injury.

RETURN TO SPORTS AND WORK — Decisions regarding return to work or sport depend upon the activity involved and the patient's pain level. Patients with rib stress fractures who perform heavy labor and athletes who train intensively should be instructed to avoid these activities for the first three weeks. Once there is no longer pain at rest, they can gradually increase their activity level. Some athletes engaged in contact sports can return to play as soon as one week after the acute injury, provided the fractured rib is protected with a flak jacket or similar device, which should be used for six to eight weeks [77].

During rehabilitation, attention should be paid to ensuring proper mechanics and eliminating training errors to avoid recurrence. Clinicians treating rib stress fractures in rowers can refer to a 2015 guideline by physicians for the British rowing team [15,16]. (See "Overview of stress fractures".)

Virtually all nonpathologic rib fractures heal well with conservative management within six weeks. Many patients are able to resume daily activities much sooner. Some patients are able to return to work within a few days as long as their occupation does not require activity that exacerbates the pain.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Thoracic trauma" and "Society guideline links: General fracture and stress fracture management in adults" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Rib fractures in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Mechanisms of injury – Rib fractures are common injuries that occur most often following direct blunt thoracic trauma but can also result from severe coughing, athletic activities (eg, rowing, swinging golf clubs), child abuse, and bone metastases. (See 'Mechanisms of injury' above.)

●Clinical features – Patients with rib fractures typically describe a history of a minor to moderate chest wall injury. Frequently, they can localize the pain to one or two ribs. Examination reveals point tenderness on a specific rib or focal tenderness caused by compression of the ribcage distant from the site of pain. A deep breath typically elicits pain at the fracture site. Rib stress fractures present with a gradual onset of activity-related chest wall pain. (See 'Clinical Features' above.)

●Diagnosis and diagnostic imaging – Rib fractures in victims of blunt trauma are generally identified clinically or by chest radiograph (CXR). A definitive diagnosis of rib fractures is not always necessary. The presence of isolated rib fractures does not have to be radiologically confirmed in all patients once associated injury has been adequately excluded, typically with a CXR, which is obtained primarily to identify pneumothorax, hemothorax, and other signs of intrathoracic injury. (See 'Diagnostic Evaluation' above.)

•In most cases when CXR is not sufficient for the identification of rib fractures, chest computed tomography (CT) should be performed. Chest CT demonstrates greater sensitivity and specificity for rib fractures compared with plain radiographs but should not be performed for the sole purpose of assessing potential rib fractures since the clinical significance of these additionally discovered fractures is generally minimal. When expertise and technology is available, emergency physician-performed bedside ultrasound is an emerging modality with test characteristics comparable to CT for identifying rib fractures. Rib radiographs have very limited utility when CT is available. (See 'Choice of supplemental imaging' above.)

•In patients with concern for stress fracture in whom definitive diagnosis will change management, magnetic resonance imaging (MRI) has become the modality of choice. Both bone scintigraphy and MRI have traditionally had better sensitivity for fracture than CT but are limited by resource availability. Bone scintigraphy requires large doses of ionizing radiation and has poor specificity. (See 'Bone scintigraphy' above and 'Magnetic resonance imaging' above.)

•A skeletal survey should be obtained in infants with rib fractures, especially multiple fractures in various stages of healing, since this raises suspicion for abuse. (See "Physical child abuse: Diagnostic evaluation and management" and 'Candidates for additional imaging' above.)

●Fracture patterns associated with internal injuries – Liver or spleen lacerations, mediastinal injury, pneumothorax, hemothorax, flail chest, and pulmonary contusion may occur but are uncommon with isolated rib injuries. An increasing number of rib fractures correlates with serious intrathoracic and intra-abdominal injuries. Displaced fractures increase the risk of internal injury and delayed bleeding. (See 'Fracture patterns associated with internal injuries' above.)

•First rib fractures are associated with greater overall injury severity and life-threatening internal injury (including injuries to the brain, spine, lungs, and pelvis).

•Fractures of superior ribs (numbers 1 to 3) reflect trauma involving significant force and the potential for injury to mediastinal structures, major blood vessels (eg, aorta), and lung parenchyma.

•Fractures of ribs 9 through 12 may be associated with intra-abdominal injury. Right lower rib fractures may be associated with hepatic injury and left lower rib fractures with splenic injury. Fractures of the posterior portion of the lower ribs can be associated with renal injury.

•Three or more adjacent ribs each fractured in two places (ie, flail chest) (figure 4) is often associated with significant morbidity from pulmonary contusion as well as injuries elsewhere.

●Management – Treatment of rib fractures should be focused on early and adequate pain relief to avoid complications (eg, pneumonia) from splinting and atelectasis. Analgesia for isolated rib fractures includes nonsteroidal antiinflammatory drugs (NSAIDs) with or without opioids. Encourage incentive spirometry to prevent atelectasis. (See 'Analgesia and pulmonary hygiene' above.)

For more severe injuries, intercostal nerve blocks are an effective approach but typically require admission. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Pain control'.)

Rib stress fractures are treated similarly to other low-risk stress fractures. Treatment begins with restriction of the inciting activity for four to six weeks followed by a gradual return to the activity as tolerated. (See 'Treatment of stress fractures' above.)

●Disposition – We typically hospitalize patients with three or more rib fractures and use a more conservative threshold for admission in older or frail adults and those at increased risk for pulmonary complications. An algorithm to assist clinicians with the disposition of patients with isolated rib fractures is provided (algorithm 1). (See 'Disposition' above.)

●Follow-up care – A follow-up evaluation six to eight weeks after the injury is reasonable, especially if the patient has persistent pain or any questions regarding ability to return to sports or work. Virtually all rib fractures heal well within six weeks. Follow-up chest radiographs are unnecessary unless indicated by clinical symptoms (eg, new shortness of breath, new or severe pain). (See 'Follow-up care' above.)

●Return to sports and work – Some patients are able to return to work within a few days, depending on their occupation, while some patients may experience prolonged pain and disability. (See 'Return to sports and work' above.)