Authors
Daniel T. DeGenova^1A, Peter Spencer², Brendan Kelly², Vishvam Mehta², Nathan Rodriguez², Dante A. DeGenova², Joseph P. Scheschuk², Benjamin C. Taylor².

1. OhioHealth Health System, Department of Orthopedics, Columbus, OH 43228, United States
2. OhioHealth Orthopedic Trauma and Reconstructive Surgeons, Grant Medical Center, Columbus, OH 43215, United States

A. Corresponding author at: OhioHealth/Doctors Hospital, 5100 West Broad Street, Columbus, OH 43228, United States. E-mail address: [email protected] (D. T. DeGenova).

Abstract

Sufficient force directed on a rib will result in a rib fracture. Diagnosis is often with plain radiographs or computed tomography scan. Typically, rib fractures are treated nonoperatively with therapy focused on pain control due to the strong correlation between pain and risk for pneumonia. Additionally, open reduction internal fixation has become more common in the last decade. This article aims to review the anatomy, presentation, diagnosis, treatment, outcomes, and complications of rib fractures.

Keywords: Rib Fracture, ORIF, Rib fracture treatment

Introduction
Accounting for 10% of blunt trauma hospital admissions, rib fractures are a frequent injury encountered in the context of orthopedic trauma [1]. The prevalence of at least one rib fracture increases to 60-80% in patients with blunt chest trauma. Most of these injuries occur due to high-energy mechanisms; however, some occur due to overuse injuries [2]. 

Diagnosis has improved over the years, mainly due to clinical suspicion as well as improvement in advanced imaging with CT scanning. This leads to a timely diagnosis which can help reduce the sequelae and morbidity of this injury. The mainstay of treatment is often nonoperative management [3]. Recently, a rise in operative management of rib fractures has become apparent. ORIF of rib fractures has been shown to reduce complications of rib fractures, including pneumonia, reduce time on the ventilator, and reduce mortality. The following is a current concept and review of the anatomy, assessment, imaging findings, diagnosis, and treatment of acute rib fractures.

Anatomy 
The osseous thoracic cage consists of 12 pairs of ribs grouped together based on the relationship of their respective costal cartilages to the sternum anteriorly. The true ribs, ribs 1-7, are connected directly to the sternal notches. The false ribs, ribs 8-10, are connected to the sternum indirectly via costal cartilages, each of which are connected to their respective superior costal cartilage, forming the costal margin. Finally, ribs 11-12 are the floating ribs, which terminate within the lateral abdominal wall musculature without any connection anteriorly [4-8].

Bony features of each rib from posterior to anterior include the head, neck, costal tubercle, costal angle, and shaft. The head of the rib is the aspect that articulates with each level of the thoracic spine via zygapophyseal joints. Ribs 1, 11, and 12 articulate with only the corresponding thoracic vertebrae, while ribs 2-10 articulate with the corresponding costal facet and the one superior. The tubercle of each rib articulates with the transverse process of the corresponding vertebrae, with the neck of the rib gapping the space between the head and tubercle. Each rib contains an inferior costal groove, in which the intercostal neurovascular bundle lays. Additionally, the first rib possesses grooves on the superior surface for the subclavian artery and vein [4,7,8]. 

The physiologic function of the thoracic cage involves respiration. The ribs are used by the diaphragm and accessory respiratory muscles to facilitate expansion or compression of the lungs during respiration. The ribs move superiorly and inferiorly, in a so-called “bucket handle” motion, while the sternum moves anteriorly and posteriorly in a so-called “pump handle” motion. These motions coordinated together allow for increased or decreased pressures, and therefore volumes, in the lungs. The accessory muscles of inspiration serve to increase the volume of the thoracic cage and include the sternocleidomastoid muscle, scalene muscles, and external intercostal muscles. The accessory muscles of expiration decrease the volume of the lungs and include the internal intercostal muscles, rectus abdominis muscle, external and internal oblique muscles, and transverse abdominis muscles. [7]

Presentation and diagnosis
Rib fractures can occur from a multitude of causes, most commonly motor vehicle accidents, falls, specifically in the elderly, and sports injuries due to overuse or direct trauma being other common etiologies [5,9-11]. Older patients are more likely to have rib fractures, along with increased morbidity and mortality as sequelae [5,11]. Children presenting with rib fractures often indicate severe trauma, as pediatric bone is more flexible. Therefore, these patients should be evaluated for child abuse [5,12]. Another significant detail of note is that iatrogenic rib fractures, such as after cardiopulmonary resuscitation, are associated with a higher rate of flail chest and in-hospital mortality [13].

Rib fractures can vary in presentation and severity, ranging from a single nondisplaced rib fracture to multiple displaced fractures resulting in flail chest [5,14]. The most typical segment for rib fracture is ribs 5-9, as the upper ribs are protected by the shoulder girdle, while the lower ribs are free to move around and therefore are less likely to fracture [4,9,10]. The location of the rib fractures can be indicative of associated injuries, as displayed by Davoodabadi et al. [9]. 

Patient symptoms in fractures can include pain, worse with deep respiration, point tenderness over the fracture site, decrease lung sounds, retention of pulmonary secretions causing pneumonia, respiratory distress, and paradoxical lung motion, as seen in flail chest. Logically, the intensity of symptoms increases with the quantity and severity of lung fractures. For example, patients with flail chest are much more likely to have severe pain and respiratory failure. For this reason, all patients with trauma or rib pain should be worked up for rib fracture to determine treatment options [15].

Diagnosis of acute rib fractures can be made clinically or with various imaging modalities. Clinical diagnosis is achieved through a thorough history and physical exam. The history of a patient with an acute rib fracture will likely include some form of trauma of the thoracic cage and pain around the injury. Physical exam findings may include tenderness, bruising, and crepitus. Additionally, flail chest can be seen with paradoxical motion of the rib cage [5]. 

Imaging is the mainstay of rib fracture diagnosis. Historically, chest radiographs have been standard for evaluating rib fractures. Assi et al. showed that the best radiographic view to detect rib fractures in patients with clinical signs of fractures is a 45-degree oblique view on expiration (Figure 1). In patients with a clear standard posterior-anterior chest X-ray, yet high clinical suspicion for a rib fracture is present, an oblique X-Ray during rapid breathing is recommended [10]. However, Sano displayed that radiography misses rib fractures to a greater extent than CT due to organ overlap, and fractures being outside the image range [16].  Similarly, Schelmerdine et al. displayed that CT had significantly more rib fractures detected, higher sensitivity for detecting the correct rib, and a higher likelihood of diagnosing any rib fracture in children [17]. For these reasons, and according to more recent literature, the gold standard for detecting rib fracture is CTscanning [5]. 

It should be noted that Magnetic Resonance Imaging (MRI) can also be used to identify rib fractures. MRI has even been shown to identify more rib fractures and have a higher sensitivity than CT. However, the authors of the study admit that MRI is not as utilitarian as CT due to decreased resolution of fracture morphology, artifacts in images due to respiration, time constraints, increased pain due to coils on the chest, and the need for patients to hold their breath [18]. 

Treatment
Traditional management of rib fractures has been nonoperative, as nearly 80% of patients with multiple rib fractures display signs of healing through CT scans three months post-injury [2,3,19,20]. Various means of supportive therapy have been described including nonsteroidal anti-inflammatory drugs (NSAIDs), paravertebral (serratus anterior and erector spinae) nerve blocks, epidural analgesic injections, pulmonary physical therapy, incentive spirometry, supplemental oxygen, and in some cases, mechanical ventilation [19-22]. As described by Wijffels et al., pain management in rib fractures is highly concerning due to its correlation with the development of pneumonia [23]. Therefore, therapy for rib fractures tends to be centered on analgesic considerations with epidural injections being the most frequently utilized. The pathomechanism for this correlation is that patients with pain will decrease tidal volume and retain mucus, rendering them more susceptible to pneumonia. 

There has been a recent increase in the usage of open reduction and internal fixation (ORIF) or rib fractures, particularly when chest wall instability is present (Figure 1). ORIF has shown promising results in a variety of patients and fracture severities. Instability of the chest wall includes flail chest, the presence of 3 consecutive ribs broken in 2 locations, and 3 consecutive bi-cortically displaced rib fractures [20]. Paradoxical motion of the thoracic cage has also been described as an indication for ORIF in some patients [24].

Elderly patients have shown particularly inconsistent results. Chen et al. claim SSFR offers diminished mortality in geriatric populations. While previously considered a contraindicated population for ORIF, Wijck et al. showed superior results with operative management in patients with mild to moderate pulmonary contusions as categorized by the Blunt Pulmonary Contusion 18 (BPC18) score [25,26]. This is contrary to findings by Sawyer et al. which displayed statistically diminished length of hospital stay and mechanical ventilation for populations older than 60 years of age when treated conservatively [27].

There is a dearth of literature regarding the surgical correction of rib fracture nonunion, as well as primary surgical intervention pertaining to ribs, which has led to emergent research on various surgical treatments and approaches [14]. One area of particular focus has been flail chest injuries which still pose an elevated mortality rate of up to 33%. This is despite advancements in critical care management with nonsurgical treatment associated with various morbidities including respiratory difficulty, ventilator support, pneumonia, increased ICU stays, and chronic pain originating from bony thorax non/malunion. A number of recent randomized controlled studies, however, have shown surgical treatment to address these issues, as well as decrease patient recovery time. The improvements conferred by surgical treatment can be attributed to modern plating technology and refined surgical approaches. Therefore, surgical stabilization of flail chest continues to garner additional validity [28,29]. Moreover, in the case of flail chest, anterior ribs and associated costal cartilages have also been effectively addressed via ORIF. The same treatment has also been suggested for far posterior or paraspinal rib fractures, which may include the costovertebral articulation and occur on the medial border of the scapula [30].

In certain clinical scenarios, ORIF may be indicated over nonsurgical treatment. Evans et al. conducted a retrospective study in which they found there was a 3.9% greater reduction in mortality for ORIF with concomitant spinal injuries as compared to nonsurgical treatment of the same injury pairing [31].

In a six-year retrospective analysis of patients who had sustained surgical or nonsurgical treatment for complex rib fractures, it was determined that earlier surgical (<72 hours post-injury) intervention had the following effects: a 3% decrease in the development of pneumonia, four fewer days spent in the ICU, and three days less spent on mechanical ventilation [32]. Similar improved outcomes as a result of early surgical intervention have been seen in additional literature as well [33].

While there is currently a sparsity in the literature for alternative techniques, ORIF with plating and screws appears to be the mainstay surgical management for patients with unstable rib fractures (Figure 2). Precontoured side and rib-specific plates with threaded holes and self-tapped screws are recommended for ORIF of the lateral rib [20]. While self-absorbing plates have been described, the results have been somewhat controversial, and metal plating remains the most frequent choice of implant [34]. While less common than lateral fractures isolated to the boney rib, costochondral and paravertebral cartilage injuries have shown improvement with plating. Fractures of the far posterior rib and paravertebral cartilage may be exposed and plated via the posterior longitudinal approach within the triangle of auscultation [30,35]. Similar to the far posterior plating technique of paravertebral cartilage, the benefits of plating the costal cartilage have shown favorable postoperative outcomes [29].

Uncommonly, after nonoperative management of acute rib fractures, patients can have persistent pain and develop nonunion of their rib fracture. This is often diagnosed on CT scan [28]. ORIF may benefit symptomatic rib fracture nonunions by minimizing pain and narcotic utilization while promoting bony healing [14]. Additionally, these patients with chronic symptomatic nonunions have been shown to undergo operative stabilization as outpatient surgery [35]. While additional research is required to determine the proper patient population, outpatient treatment could decrease postoperative complications and cost to the patient and healthcare system. 

Complications
Blunt thoracic trauma presents with a myriad of complications, both long and short-term. Those pertaining specifically to rib fractures are pneumonia, chest pain, chest wall contusion, hemothorax, pneumothorax, contusion of internal thoracic organs, pneumomediastinum, sternal or scapular fracture, bony nonunion and flail chest, [4,5,9]. The associated pneumonia, however, is the most significant as it has been closely correlated with mortality [36-38]. A prospective study of 203 patients with rib fractures found 53% to have chronic disability and 22% to have chronic pain at 6 months post-injury [38]. When considering complications of nonoperative management, patients are generally faced with an exacerbation of previously described symptoms. 

This is contrary to complications of operative management, which have been isolated as the direct result of surgery-related issues such as surgical site and hardware infections. The occurrence of surgical site and hardware infections is relatively low and has been documented from 2.2-4.1% [39]. As surgical management becomes more commonly utilized in rib fractures, additional retrospective studies are needed to determine the technique’s longevity. Furthermore, in a systematic review of 48 studies with 1952 patients who received ORIF for flail chest, it was found that there were additional complications including wound and fracture-related infection (3.5%), symptomatic nonunion (1.3%), and mortality (2.9%). Notably, pulmonary complications (30.9%) were found to have the highest incidence in this patient demographic [40,41].

Conclusion
Rib fractures are common injuries in the traumatized patient. These injuries range from nondisplaced fractures to flail chest injuries leading to pulmonary complications. Diagnosis is often made with the combination of radiographs and CT scan. Treatment consists of nonoperative management with pain control and incentive spirometry to ORIF to help reduce pulmonary complications and decrease ventilator time. The review article described the presentation, diagnosis, treatment, outcomes, and complications of rib fracture management.

Photo 1 | Photo 2

Figure Legends
Photo 1. Anteroposterior radiograph demonstrating right sided 6-9 rib fractures with flail chest.

Photo 2. Postoperative radiograph of the previously mentioned patient after undergoing open reduction and internal fixation of right sided rib fractures. 

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