How to repair broken ribs

How is a broken rib treated?

Most broken ribs take about six weeks to heal. While you’re on the mend:

If you have a more serious injury, you may need additional treatment or possibly surgery. For example, if your lung has been punctured by the sharp end of one of your ribs, you may need to have a procedure done to remove air or blood from inside your chest. Some people whose ribs are badly injured might need to have them repaired with metal plates, but this is rare.

  • Take a break from sports to allow yourself to heal without hurting yourself again. Put ice on the area to relieve pain.
  • Take pain medicine like acetaminophen or ibuprofen. If you need something stronger, your doctor may prescribe something for you.
  • Take deep breaths to avoid pneumonia. A lung infection is the most common thing you can get with rib fractures. Your doctor may give you a simple device to encourage you to breathe deeply.
  • Don’t wrap anything tightly around your ribs while they’re healing. You don’t want anything to limit your breathing.

PMC

Discussion

Analysing the literature reveals that patients with rib fractures have considerable morbidity and mortality. However, one of the challenges in this analysis is that patients with flail chest and multiple rib fractures are often combined and regarded as one group. This makes interpreting these results difficult, as flail chest patients are obviously more seriously injured, and one would expect the morbidity and mortality rates to be higher in this group. Patients with multiple rib fractures, however, represent a far larger and more interesting group from an economic health perspective.

The available data concerning flail chest patients and surgical fixation is of a higher scientific level than the data on single and multiple rib fractures, as several randomised controlled trials have been published on flail chest patients. Only cohort studies are available for multiple rib fracture patients.

The injury patterns and effects of flail chest were well described even as far back as the early 20th century . The physiological mechanism and effects resulting in pulmonary complications are well understood. Patients with flail chest have paradoxical movements of the flail part of the thorax, which reduces the efficiency of the ventilation in the lung. Less well known is that due to the pressure changes in the thoracic cavity, venous return of blood to the heart is reduced. This in turn has a negative effect on the cardiac output and thus the hemodynamic status of the patient. Apart from injuries of the chest, the prognosis of a flail chest patient is of course also determined by other injuries. These patients have sustained high-impact trauma, which generally results in multiple injuries.

Pulmonary complications are well known. All flail chest patients have some degree of lung contusion, which in combination with reduced movement and pain leads to an elevated risk of contracting pneumonia. The rates in the literature range from 10% and 70%, predominantly between 20% and 40% . The risk factors for pneumonia are age, the number of rib fractures, and whether pain is persistent.

Apart from pneumonia, mortality is a significant issue with flail chest. Rates as high as 51% have been described . Of course, this is not only determined by pulmonary-related problems, but also by the other injuries that a patient sustains. Nonetheless, it is interesting to note that mortality rates are reduced if the rib fractures of flail chest patients receive operative stabilisation .

Several studies have described considerable benefits of the surgical repair of flail chest. Patients treated surgically have shorter ICU stays, less need for ventilator support, reduced pneumonia, reduced HLOS, and reduced mortality.

The highest level of evidence (level 2) has been provided by the randomized studies of Tanaka et al. , Granetzny et al. , Marasco et al. , and Wu et al. . They all describe a beneficial effect of the surgical fixation of flail chest on the length of ICU stay, ventilator support duration, and hospital length of stay with a reduction of 8 days on average. Tanaka et al. and Granetzny et al. describe a reduction in mortality and an average reduction of pneumonia of 46%. A recent Cochrane review was also based on these studies . They conclude that surgical stabilization seems to be beneficial in flail chest patients, but the patient numbers are relatively small and studies do not indicate which flail chest patients to treat operatively and which conservatively.

The English National Institute of Clinical Excellence has decided that operative repair of flail chest injuries can be offered routinely, based on the current level 2 evidence in the literature.

However, not every case of flail chest is the same. It is important to understand the difference between the radiological definition of flail chest as stated above and the clinical definition of flail chest which is: “a chest wall injury with ipsilateral consecutive double broken ribs resulting in paradoxical movement of the chest wall.” A potential problem with a focus on the clinical definition is underestimating lateral and posterior flail chest injuries. These regions of the chest are covered with thick layers of muscle and the scapula, making it virtually impossible to see the paradoxical movement. When operating on posterior flail chest patients it becomes apparent that these lateral and posterior injuries are highly unstable. We therefore propose that the radiological definition be used when identifying patients with flail chest. It is important to understand that this is only possible using computed tomography (CT). A conventional X-ray for rib fractures may underestimate the amount and extent of rib fractures by as much as 50%, as well as missing other relevant intrathoracic injuries .

Using the radiological definition in turn poses the risk of identifying too many patients eligible for surgical treatment of flail chest, resulting in over-treatment. The subgroup of patients who need surgical treatment are those with an unstable chest causing pulmonary insufficiency. Identifying these patients can be done by first choosing the patients who clearly exhibit pulmonary insufficiency ( i.e., those who are ventilator-dependent). The next step is to look for radiological evidence of instability, as shown by some form of dislocation of the rib fractures on a CT scan. Dislocation is defined as displacement of 2 mm or more (“in the algorithm, these are referred to as B or C fractures”). These factors are incorporated into the following algorithm for patients with flail chest (Fig. 1).

Algorithm for patients with flail chest.

In the above algorithm, patients can be shunted to the isolated rib fracture treatment protocol. The next algorithm for this protocol can be used for patients with rib fractures that have no flail component.

As stated previously, a review of the literature demonstrated a substantially larger number of publications on the flail group compared to the scientific evidence concerning patients with multiple rib fractures. An analysis of the literature regarding the latter group has revealed several factors predictive of the prognosis of a patient. The first factor is age. There is a significant relationship between the age of a patient and the risk of rib fracture complications. Several articles have described the age of 45 years as a threshold between a relatively good prognosis and a poorer prognosis . The second factor is the number of rib fractures. An exponential relationship has been observed between the number of rib fractures and the risk of complications due to the fractures, pneumonia, mortality, and so on. The third factor is pain, which is often underestimated. A substantial number of rib fracture patients have prolonged pain, defined as a period greater than 6 weeks . Pain itself causes decreased respiratory motion and decreased coughing, putting the patient at risk for developing pneumonia. In general, a visual analogue scale (VAS) score >6 is recognized in the scientific literature as substantial. As the fourth and final factor, the authors have included the amount of dislocation of the rib fractures. A dislocation of 2 mm or more is considered substantial, because such dislocation is similar to that observed in flail chest patients. Dislocated rib fractures imply that there is a degree of instability, which in turn will have an effect on chest movement and pain, putting the patient at risk for pulmonary complications. Combining the above factors results in the following algorithm (Fig. 2).

Algorithm for rib fracture management. VAS, visual analogue scale.

In this algorithm, the operative stabilisation of rib fractures only occurs under the following conditions: (1) if a patient is older than 45 years of age and has more than 4 rib fractures that are painful, as shown by a VAS >6 (regardless of adequate painkillers), and has dislocated rib fractures; or (2) if a patient is younger than 45, has more than 6 rib fractures (which poses a risk for pulmonary complications, as described by Bergeron et al. and Flagel et al. ) and the rib fractures are painful (VAS >6) and dislocated; or (3) if a patient is younger than 45 and has fewer than 6 rib fractures, but with substantial displacement causing a deformity/impalement. This pathway is also offered for older patients (>45 years) with either a few fractures and a substantial deformity/impalement or low pain level (VAS <6) and a substantial deformity.

In all other cases, non-operative treatment is offered to the patient.

Patient Education

Rib Fracture (Broken Rib)

Your ribs are curved bones in your chest. They help protect your lungs and expand and contract when you breathe. Children’s ribs bend easily and can often withstand a blow or fall. But adult ribs are more likely to break (fracture) under stress. Even coughing or a hard sneeze can fracture a rib.

When to go to the Emergency Room (ER)

Although they can be painful, most rib fractures aren’t serious. But they often make it hard to cough or breathe deeply. Get medical care right away if you have:

  • Trouble breathing.

  • Nausea, vomiting, or stomach pain with a sore or bruised rib.

  • Pain that worsens over time.

  • An injury to the chest or stomach.

What to expect in the ER

Here is what will happen in the ER:

  • A healthcare provider will ask about your injury and examine you carefully.

  • An X-ray of your chest will likely be taken to show any major damage to ribs and lungs. But ribs can have small breaks that don’t show up on X-rays, even though they still hurt.

  • You may be given medicine to ease your discomfort.

  • In rare cases, rib fractures can cause a lung to collapse or lead to bleeding in the chest. In these cases, a tube will be inserted into the chest to reinflate the lung or drain the blood.

Follow-up

You are likely to heal in 6 to 8 weeks. Most rib fractures heal on their own with no lasting effects. Call your healthcare provider right away if you notice any of these symptoms:

  • Increased chest pain

  • Shortness of breath

  • Fever or chills

  • Coughing up blood

Fractured Rib

Topic Overview

What is a fractured rib?

A rib fracture is a crack or break in one of the bones of the rib cage. A break in the thick tissue (cartilage) that connects the ribs to the breastbone may also be called a fractured rib, even if the bone itself is not broken.

The most common cause of a fractured rib is a direct blow to the chest, often from a car accident or a fall. Coughing hard can also fracture a rib. This is more likely to happen if you have a disease that has made your bones weak, such as osteoporosis or cancer.

What happens when you break a rib?

Your ribs have two main jobs:

  • They protect the organs in your chest.
  • They help you breathe by keeping space open inside your chest while the muscles you use to breathe squeeze in, or contract. This leaves plenty of space for your lungs to fill up with air.

The muscles used for breathing pull on the ribs, so breathing may be very painful when you have a fractured rib.

It is important to see a doctor after a rib injury. A blow that is hard enough to fracture a rib could also injure your lungs, spleen, blood vessels, or other parts of your body. A common injury when you have a fractured rib is a punctured or collapsed lung (pneumothorax).

Flail chest is a serious problem that happens when three or more ribs are broken in more than one place. If you have flail chest, the broken area can’t hold its shape when you take a breath. This leaves less space in your chest for your lungs to open and air to flow in. It also makes it harder for the muscles to work well, so it’s harder to take a breath.

What are the symptoms?

A fractured rib may cause:

  • Mild to severe pain in the injured area.
  • Pain when you breathe.
  • Pain around the fracture when someone pushes on your breastbone.

If you can’t breathe normally because of your injuries, you may:

  • Feel short of breath.
  • Feel anxious, restless, or scared.
  • Have a headache.
  • Feel dizzy, tired, or sleepy.

How is a fractured rib diagnosed?

Your doctor will ask questions about your injury and do a physical exam. The doctor may:

  • Push on your chest to find out where you are hurt.
  • Watch you breathe and listen to your lungs to make sure air is moving in and out normally.
  • Listen to your heart.
  • Check your head, neck, spine, and belly to make sure there are no other injuries.

You may need to have an X-ray or other imaging test if your doctor isn’t sure about your symptoms. But rib fractures don’t always show up on X-rays. So you may be treated as though you have a fractured rib even if an X-ray doesn’t show any broken bones.

How is it treated?

Most fractured ribs are treated at home and will heal on their own over time. Home treatment will help you manage the pain while you heal. Pain relief can help you feel better and let you take deeper breaths.

A fractured rib usually takes at least 6 weeks to heal. To help manage the pain while the fracture heals:

  • Put ice on the injured area.
  • Get extra rest.
  • Take pain medicine such as ibuprofen or naproxen. Your doctor may prescribe a stronger pain medicine if over-the-counter medicines don’t work.

While you are healing, it is important to cough or take the deepest breath you can at least once an hour. This may help prevent pneumonia or a partial collapse of the lung tissue.

If you have fractured your ribs and you have not injured your neck or back, it is a good idea to lie on your injured side. This may seem odd at first, but it will let you take deeper breaths.

In the past, it was common to tape or tightly wrap the injured rib area. But you should not do this, even if it eases your pain. It can keep you from taking deep breaths, and it could cause parts of your lung to collapse or could increase your risk for pneumonia.

Rib fracture – aftercare

Apply an ice pack 20 minutes of every hour you are awake for the first 2 days, then 10 to 20 minutes 3 times daily as needed to reduce pain and swelling. Wrap the ice pack in a cloth before applying to the injured area.

You may need prescription pain medicines (narcotics) to keep your pain under control while your bones heal.

  • Take these medicines on the schedule your provider prescribed.
  • DO NOT drink alcohol, drive, or operate heavy machinery while you are taking these medicines.
  • To avoid becoming constipated, drink more fluids, eat high-fiber foods, and use stool softeners.
  • To avoid nausea or vomiting, try taking your pain medicines with food.

If your pain is not severe, you can use ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn). You can buy these pain medicines at the store.

  • These should be avoided for the first 24 hours after your injury since they may lead to bleeding.
  • Talk with your provider before using these medicines if you have heart disease, high blood pressure, kidney disease, liver disease, or have had stomach ulcers or internal bleeding in the past.
  • DO NOT take more than the amount recommended on the bottle or by your provider.

Acetaminophen (Tylenol) may also be used for pain by most people.

Tell your provider about any other medicines you are taking as drug interactions may occur.

Broken Rib Treatment

The treatment for a broken rib is simple: it can heal on its own with proper rest, but can take approximately six weeks to completely heal. In the meantime, you may experience a significant amount of pain, which can be remedied with pain relievers and by icing the affected area. In more serious cases, medical attention may be required.

Causes of Broken, Fractured, and Bruised Ribs

Rib injuries are most commonly caused by chest trauma, as a result of motor vehicle accidents, contact sports collisions, or falling. Ribs can also be bruised from severe coughing.

Fractured (or cracked) ribs are as painful as fully broken ribs, but they aren’t as dangerous. The jagged edge of a broken rib can damage major blood vessels or internal organs, if not properly treated.

How to Tell If Your Ribs Are Broken

If you’ve experienced trauma to your upper torso or chest area, pay attention to the pain you feel when you breathe in. A fractured, broken, or bruised rib can feel very painful when breathing in, which may result in taking shallow breaths.

When this happens, it’s important to work through this pain and continue taking deep breaths or breathing regularly. Continuous shallow breathing can result in the development of serious chest infections, such as pneumonia.

You may also notice swelling and tenderness around your chest or develop bruising on the skin of the area.

Treating Your Broken Ribs at Home

In most cases, ribs are excellent at healing themselves. However, during your recovery time, it’s important that you get adequate rest and tend to the pain to optimize healing. This includes:

  • Taking ibuprofen or paracetamol pain relievers regularly.
  • Using an ice pack to reduce the pain and swelling around your chest.
  • Resting when needed, which means taking time off work if your job involves physical labor.
  • Staying mobile when not resting, which can help your breathing and clear mucus from your lungs.
  • Holding a pillow to your chest when you need to cough.
  • Practicing breathing exercises to keep your lungs clear.

If you’re experiencing extreme pain or your ribs haven’t healed after six weeks, visit a medical professional. FastMed Urgent Care offers affordable and compassionate care, and our healthcare professionals strive to see each of our patients promptly, making your visit as fast as possible.

Find a FastMed near you to get the care you need for your injured ribs.

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Sources:

Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/broken-ribs/diagnosis-treatment/treatment/txc-20169657

Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/broken-ribs/home/ovc-20169623

NHS: http://www.nhs.uk/conditions/rib-injuries/Pages/Introduction.aspx

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