Rippenbruch

Rib fracture: description

The rib fracture is the most common injury to the rib cage. Most of the fourth to ninth rib is affected. The rib may break next to the sternum, front, sides and back. But are also possible combined fractures, so-called broken pieces. If someone has broken three or more ribs, doctors talk about a rib series fracture.

Man has twelve pairs of ribs. The first ten pairs of ribs are connected via cartilage to the sternum, not the bottom two pairs of ribs. The ribs, sternum and thoracic spine together form the skeleton of the ribcage (thorax).

Rib fracture: symptoms

Typical rib fracture symptoms are pain over the affected side, which increase during deep inhalation and exhalation, coughing, sneezing, and movement. Increasing difficulty breathing and circulatory problems occur in complex thorax injuries. In case of such signs, a doctor should be consulted immediately as complications may occur.

The pressure on the broken rib also causes pain. In addition, when pressure is applied to the affected area, sounds (such as crunching) can sometimes be heard and an accumulation of air in the skin (skin emphysema) can be felt. In some cases you can feel the broken rib from the outside as a step in the skin.

Accompanying injuries in rib fracture

Rib fractures are sometimes accompanied by further injuries. For example, the injury may cause blood or air to enter the pleural space and cause pneumonia or hematothorax. This occurs much more frequently in rib series fractures than in simple rib fractures.

Furthermore, the lungs may be crushed or injured. In addition, a so-called pneumomediastinum can arise: Air has accumulated in the medullary space (mediastiunum).

If the first to second ribs are broken, the large vessels such as the subclavian artery and vein (A. and V. subclavia) and the main artery (aorta) may be injured. Simultaneous injury to the trachea, bronchi, heart muscle and surrounding nerves (such as the nerve plexus = brachial plexus) is possible.

If the lowest rib breaks, the liver, spleen, kidneys and diaphragm may also be damaged. In a fracture of the sternum, there is a risk that the heart has been squeezed or the thoracic spine has been damaged.

Rib fracture: causes and risk factors

A rib fracture usually arises in the context of a direct or indirect trauma. This happens, for example, when someone slips in the bathroom and crashes against the sink or bath. Often a fall in the stairwell is the cause of broken ribs. Basically, acts of violence of any kind can lead to a rib fracture.

If there is no trauma, a disease-related break must be considered, for example due to metastases or osteoporosis (bone loss).

If only one rib is broken, it is usually an isolated injury that rarely affects deeper structures of the rib cage. However, if there is a rib fracture of the first or second rib, this usually speaks for a large impact, as these ribs are well protected by the collarbone, shoulder blade and shoulder muscles – it requires a strong leverage that these ribs break.

The abdominal organs, such as the liver and spleen, are usually protected from trauma by the bony rib cage. However, pointed fragments that result from a broken rib can injure these organs.

In a rib serial fracture, where three or more ribs are broken, breathing may be restricted, not only because of the pain but also because of the unstable chest wall.

It is very rare for a rib fracture to damage the pleura, because the broken rib protrudes inwards into the ribcage. As a result, air enters the space between the chest wall and the lungs. This leads to a so-called pneumothorax (air chest), which manifests itself through shortness of breath. The treatment of a pneumothorax belongs in the hands of a doctor.

Rib fracture: examinations and diagnosis

If you suspect a broken rib, you should consult a doctor for orthopedics and traumatology. He will ask you first about the accident and your medical history and then perform a clinical examination. Some questions from the doctor might be:

• How did the accident happen?
• Was there a direct or indirect trauma?
• Where is the possible fracture?
• How do you describe the pain?
• Were there any previous injuries or previous damage?
• Have you had any complaints before?

The diagnosis of a simple rib fracture can usually be deduced from the medical history, the description of the accident and the symptoms. He will examine you for a more detailed explanation. He examines the affected area after deformities or swelling. By carefully pressing the chest gently he can narrow down the location of the possible rib fracture.

In addition, the doctor taps and listens to the lungs for signs of possible concomitant injuries (such as accumulation of air or blood in the pleural space).

Imaging procedures

To investigate the suspicion of a rib fracture, the chest is X-rayed (chest X-ray). X-rays are taken in two planes. If there is no fracture on the first X-ray, this does not exclude a rib fracture. Often a rib fracture is diagnosed by x-rays only after weeks, when a callus (newly formed bone tissue) is seen.

In case of unclear diagnosis, a computed tomography (CT) can be performed additionally.

In addition, a rib fracture of the first to third rib should be searched for collateral injuries. These ribs are protected by the shoulder girdle and soft tissues – a break there is an expression of considerable violence. Patients with difficult chest wall injuries are usually affected by an unstable chest.

In the case of a deep rib fracture (fracture of the ninth to twelfth ribs), it is important to note a potential injury to the liver on the right side and potential spleen injury on the left side. Therefore, these patients usually get an additional ultrasound scan to rule out such injuries.

Rib fracture: treatment

In young athletic patients with an isolated rib fracture, a tape or roof tile dressing may be useful. Otherwise, the rib fracture is not actually fixed with a dressing, otherwise there is a risk that the patient develops pneumonia.

Treatment of pain

The pain in a rib fracture can be alleviated with painkillers and a nerve block in the appropriate region.

For moderate to moderate pain, non-steroidal analgesics are usually taken. For severe pain, opioids are very strong painkillers). However, it should be noted that they have a sedative effect and limit breathing.

For nerve block a local anesthetic is injected to the lower edge of the rib in question. This stuns the intercostal nerves, making the patient pain free for about six to eight hours.

Another very effective pain treatment is the so-called thoracic epidural anesthesia. Painkillers or local anesthetics are injected into the peridural space in the spinal canal, which inhibits the pain-conducting nerve fibers for some time. Thoracic epidural anesthesia is especially used for severe pain, rib ligament fractures and bilateral fractures.

respiratory therapy

The physical respiratory therapy is the second pillar of therapy in the rib fracture. With the help of physical therapy, the patient is instructed to breathe deeply and to support coughing. With certain breathing techniques and inhalations, the secretion is dissolved and transported away better. The treatment can be done on an outpatient basis.

Inpatient treatment

Some patients with broken ribs are hospitalized in hospital, such as a broken rib or fracture of the first to third ribs. So the patient can be carefully monitored and treated. Intubation and ventilation are sometimes recommended, such as complications such as tension pneumothorax (a life-threatening form of pneumothorax). In rare cases, rib fractures must be operated on.

Rib fracture: disease course and prognosis

The breakage of one or a few ribs is usually harmless and heals without complications.

In a rib series fracture (in which multiple ribs are broken), the respiratory mechanics may be disturbed. Rarely, a rupture of the rib leads to an injury to the pleura, resulting in a pneumothorax (air chest). Failure to treat these rib fracture complications can be life-threatening. With timely therapy, however, they are easy to control and heal without consequences.

Since coughing and deep inhalation and exhalation are often avoided due to pain of the ribs, there is always the risk of pneumonia.

Rib fracture: healing time

If there are no complications heals Rippenbruch usually in about four to six weeks. If symptoms persist beyond this period, the cause may be delayed bone healing or, in rare cases, painful non-union.