Rib fracture

Mechanism and types of injuries

Fractures occur due to traumatic force, which can be direct or indirect.

• Direct impact: the bone breaks precisely at the point of contact with the injuring object. The number of broken ribs depends on the area and force of the impact.
• Indirect impact (compression): fractures occur away from the point of force application and are often multiple. If the chest is compressed anteroposteriorly, the ribs break along the axillary lines; during lateral compression — near the spine or sternum. Due to hyperextension of the rib, its inner cortex breaks first, which is often accompanied by injury to the pleura and lung tissue.

Depending on severity, fractures are divided into isolated (1–2 ribs) and multiple, unilateral and bilateral, with or without displacement. The most severe variant is double («flail») fractures.

Double fractures and paradoxical breathing

With severe impact on the rib cage arch, a section of the chest wall can break out, forming a mobile segment — a flail chest. This disrupts the overall structural framework of the chest and leads to paradoxical breathing.

• At the moment of inspiration: the fenestrated fracture caves inward, compressing the injured lung. Air from it flows over to the healthy side.
• At the moment of expiration: the flail segment bulges outward, and stale air from the healthy lung rushes into the injured one.

Such biomechanics is aggravated by synchronous pendular shifting of the mediastinum. As a result, cardiopulmonary failure rapidly develops and a real threat of pleuropulmonary shock arises.

Clinical presentation and diagnostics

A patient with a rib fracture usually assumes a forced posture: leans toward the affected side and supports the chest with their hand, trying to limit its mobility. Breathing is rapid and shallow.

Specific symptoms:

1. «Broken breath» sign: an attempt to take a deep breath is suddenly interrupted due to a sharp attack of pain.
2. Compression sign: cautious opposing pressure on the chest causes pain specifically at the site of the broken rib.
3. Crepitation: a reliable sign determined by palpation or auscultation over the trauma zone.

The baseline diagnostic method is radiography of the entire chest in an anteroposterior projection. However, due to shadow overlapping, fewer fractures are visible on the image than actually exist, and the cartilaginous zone is not visualized at all. Therefore, clinical data play a leading role, and CT imaging is considered the most informative method.

Treatment: from conservative to surgical

Most rib fractures fuse perfectly on their own. The main goal of treatment is not bone fixation, but the maintenance of pulmonary ventilation to prevent post-traumatic (hypostatic) pneumonia.

• Pain management: the cornerstone of therapy. Local novocaine blockades are used, and in severe injuries — epidural anesthesia or Vishnevsky vagosympathetic blockade. Adequate pain relief allows the patient to breathe deeply and cough up secretions.
• Regimen: physical therapy and breathing exercises are prescribed from the first day. Using tight, compressing bandages is strictly prohibited.
• Surgical treatment: indicated for flail chests to restore structural framework. Broken ribs are fixed with metal plates, stapling clips (including under video-assisted thoracoscopic control) or external splints are used.

Complications

Patients with complications must be monitored in the intensive care unit, as rib trauma can be accompanied by damage to internal structures:

• Pneumothorax: accumulation of air in the pleural cavity. The most dangerous is internal tension pneumothorax, in which air enters the pleura during inspiration and does not exit during expiration, rapidly compressing the lung and shifting the mediastinum. Requires immediate drainage.
• Hemothorax: accumulation of blood in the pleura due to rupture of vessels or the lung. It can be small (up to 500 ml), moderate, and large. With ongoing bleeding, blood may clot and then liquefy again due to fibrinolysis.
• Subcutaneous emphysema: escape of air under the skin. An important diagnostic marker: if emphysema first appears on the neck rather than over the fracture, it indicates damage to the mediastinum.

Class and exam questions

What else to study on this topic

• Technique of Vishnevsky vagosympathetic blockade
• Classification and drainage methods for hemothorax
• Pathogenesis of tension pneumothorax
• Types of external fixators for chest wall stabilization
• Epidural anesthesia in traumatology

Other topics in the "Specialized Adult Traumatology" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.