Rib Fracture and Pneumothorax Complication


Overview

A rib fracture is one of the more common injuries to the chest with rib fractures as the most common thoracic injury from blunt force trauma. Uncomplicated single rib fractures can be managed easily. However, multiple rib fractures may result in a pneumothorax, a life-threatening emergency.

There are 12 pairs of ribs that circle the chest for the primary purpose of protecting the heart and lungs. All of the ribs have a posterior attachment to the spine, but only 10 of the ribs have an anterior attachment to the sternum via costal cartilage. The flexible costal cartilage allows for the rib cage to expand during inspiration.

The last two ribs are known as “floating” ribs because they do not have an anterior attachment. Because these two ribs remain unattached, a fracture to these ribs may result in associated damage to the kidneys, liver, or spleen.

Located between each rib are small external and internal intercostal muscles. These muscles are responsible for elevating and then returning the ribs to their natural position during breathing. These muscles can also be injured during a chest injury.

What types of rib injuries are there?

There are a number of possible injuries involving the ribs including stress fractures, nondisplaced simple fractures, displaced multiple fractures, and costochondral separation (separation between the costochondral cartilage and the rib).

Rib stress fractures can be seen in athletes with a history of a violent muscle contraction as can be seen in the sport of weightlifting. Stress fractures can also be seen in golfers, rowers, and baseball pitchers.

A stress fracture is a small partial fracture in the bone. These can be painful, but are not dangerous and have a good prognosis with rest and time for healing.

Simple nondisplaced rib fractures are most commonly seen in ribs five through nine from blunt force to the front or back of the body. A simple nondisplaced fracture means that there is a break though the bone, but the bone ends remain in their original position. These types of fractures also have a good prognosis with rest.

However, displaced multiple fractures can be life-threatening. Displaced multiple fractures can leave sharp bony fragments which may puncture the pleural sac surrounding the lungs. This can lead to a pneumothorax or a collapsed lung. These types of injuries are the most serious with the athlete needing immediate emergency medical treatment.

The last common injury in and around the ribs is a separation of the anterior rib from its costochondral attachment. The costochondral cartilage attaches the anterior rib to the sternum. This type of injury can occur during a collision or as the result of a severe twisting motion of the thorax.

This type of injury can either result in a tear between the sternum and the costochondral cartilage or a tear between the costochondral cartilage and the rib. The tear may be accompanied by a “popping” sound with localized sharp pain for a few days. Unfortunately this type of injury may result in chronic pain.



Symptoms

What are the complications of rib fractures?

The most severe and critical complication of displaced rib fractures is a pneumothorax. A displaced rib fracture can puncture the lungs and the pleural sac surrounding the lungs effectively deflating the lung on the side of the pleural puncture. As the lung deflates, the athlete will have increasing pain and difficulty breathing.

A pneumothorax should be suspected if an athlete exhibits any of the following signs and or symptoms:

• Anxiety/restlessness
• Painful breathing
• Increased heart rate
• Cyanosis
• Distended neck veins
• Severe chest pain
• Decreased or absent breath sounds of affected lung
• Decreased blood pressure
• Asymmetric chest expansion

If a pneumothorax is suspected, emergency medical services should be immediately called. The athlete should be kept calm and quiet with a focus on slow and controlled breathing.

What are the signs and symptoms of a rib fracture?

If the mechanism of injury for the athlete involves a direct blow to the ribs or an indirect force resulting in the compression of the rib cage, the presence of the following signs and symptoms may indicate a rib fracture:

• Localized swelling
• Discoloration
• Increased pain on deep inspiration
• Pain on palpation of injured area
• Visible deformity
• Shallow breathing
• Increased pain on trunk rotation and lateral flexion away from fracture site
• Cyanosis
• Rapid, weak pulse and low blood pressure with multiple fractures
• Individual may lean towards injured side

How is a rib fracture diagnosed?

Because the symptoms of a bruised rib and fractured rib are very similar, an x-ray should be ordered to rule out a fracture. The diagnosis should also include a thorough medical history, physical examination, and auscultation (exam with a stethoscope to listen for breath sounds).



Causes

Who gets rib fractures?

Single and multiple rib fractures have the highest incidence in collision sports including wrestling and football and contact sports such as basketball and soccer. Stress fractures can be seen in athletes with repetitive upper extremity motions as seen in the sports of throwing athletes, golfers, and rowers.

What causes rib fractures?

Rib fractures can be caused by both direct and indirect forces. Direct forces would include being hit, kicked, or punched with the resulting fracture at the site of contact.

An indirect force can cause rib fractures through general compression of the rib cage as when a football player is compressed by another player during a tackle. The weight of the opposing player can compress the injured player against a hard surface. If the external force is stronger than the tensile force of the ribs, the bones can be fractured.



Prevention

What can I do to prevent a rib fracture?

Rib injuries often occur through accidental injury in sports. However, when it applies, protective gear should be properly fitted and worn.



Treatment

What is the treatment for a rib fracture?

The length of recovery depends on the severity of the injury. Sports injury treatment using the P.R.I.C.E. principle - Protection, Rest, Icing, Compression, Elevation can be utilized as well as the use of anti-inflammatory or pain medication.

Unlike other fractures in which the bone is immobilized to reduce pain and enhance the healing process, the ribs cannot be effectively immobilized because they need to expand in order for the individual to breathe. Because of this, pain medication is used to make the athlete more comfortable.

There appears to be some controversy as to whether to strap or tape fractured ribs. Some sources suggest taping while others state that the taping is not recommended because it may aggravate the injury.

Recovery – Getting back to Sport

Return to sport will depend on a number of factors including the number of ribs fractured and the severity of the fractures. Simple fractures should heal within 4 – 6 weeks. However, each athlete is unique and return to sports should be individually determined.

A sports medicine physician can determine if the fracture has healed through the use of a post-injury x-ray. This is especially important for athletes competing in collision or contact sports.

Physicians may allow the athlete to begin noncontact activity sooner if the athlete is pain-free during deep inspirations and rotatory and lateral movements.

When Can I Return to Play?

An athlete can return to competition when he/she has been released by his/her personal physician to return to sports and when the athlete is pain-free with all trunk movements.

For athletes returning to football, a flak jacket or rib vest can be worn to protect the area from reinjury.

If you suspect that you have a rib fracture or pneumothorax complication, it is critical to seek the urgent consultation of a local sports injuries doctor for appropriate care. To locate a top doctor or physical therapist in your area, please visit our Find a Sports Medicine Doctor or Physical Therapist Near You section.

References

Anderson, M.K., Parr, G.P., & Hall, S.J. (2009). Foundations of Athletic Training: Prevention, Assessment, and Management. (4th Ed.). Lippincott Williams & Wilkins: Baltimore, MD.

Arnheim, D. & Prentice, W. (2000). Principles of Athletic Training. (10th Ed.). McGraw-Hill: Boston, MA.

Bahr, R. & Maehlum, S. (2004). Clinical Guide to Sports Injuries. Human Kinetics: Champaign, IL.

Rouzier, P. (1999). The Sports Medicine Advisor. SportsMed Press: Amherst, MA.



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