Abstract
Fractured ribs are among the most common causes of chest wall pain; they are usually associated with trauma to the chest wall. In osteoporotic patients or in patients with primary tumors or metastatic disease involving the ribs, fractures may occur with coughing (tussive fractures) or spontaneously.
The pain and functional disability associated with fractured ribs are largely determined by the severity of the injury (e.g., number of ribs involved), the nature of the injury (e.g., partial or complete fracture, free-floating fragments), and the amount of damage to surrounding structures, including the intercostal nerves and pleura. The pain associated with fractured ribs ranges from a dull, deep ache with partial osteoporotic fractures to severe, sharp, stabbing pain that may lead to inadequate pulmonary toilet. In the absence of significant trauma, the clinician should highly suspect the possibility of malignant lesions of the ribs.
Keywords
chest wall pain, fractured ribs, sports injury, diagnostic sonography, ultrasound guided injection, intraarticular injection, chest pain, non-cardiogenic chest pain, devil’s grip, acute herpes zoster
ICD-10 CODE S22.39xA
The Clinical Syndrome
Fractured ribs are among the most common causes of chest wall pain; they are usually associated with trauma to the chest wall ( Fig. 67.1 ). In osteoporotic patients or in patients with primary tumors or metastatic disease involving the ribs, fractures may occur with coughing (tussive fractures) or spontaneously.
The pain and functional disability associated with fractured ribs are largely determined by the severity of the injury (e.g., number of ribs involved), the nature of the injury (e.g., partial or complete fracture, free-floating fragments), and the amount of damage to surrounding structures, including the intercostal nerves and pleura. The pain associated with fractured ribs ranges from a dull, deep ache with partial osteoporotic fractures to severe, sharp, stabbing pain that may lead to inadequate pulmonary toilet. In the absence of significant trauma, the clinician should highly suspect the possibility of malignant lesions of the ribs ( Fig. 67.2 ).
Signs and Symptoms
Rib fractures are aggravated by deep inspiration, coughing, and any movement of the chest wall. Palpation of the affected ribs may elicit pain and reflex spasm of the musculature of the chest wall. Ecchymosis overlying the fractures may be present. The clinician should be aware of the possibility of pneumothorax or hemopneumothorax. Fractures of the first rib may produce a Horner’s syndrome ( Fig. 67.3 ). Damage to the intercostal nerves may produce severe pain and result in reflex splinting of the chest wall that further compromises the patient’s pulmonary status. Failure to treat this pain and splinting aggressively may result in a negative cycle of hypoventilation, atelectasis, and, ultimately, pneumonia.
Testing
Plain radiographs or computed tomography (CT) scans of the ribs and chest are indicated for all patients who present with pain from fractured ribs, to rule out occult fractures and other bony disorders, including tumor, as well as pneumothorax and hemopneumothorax (see Fig. 67.2 ). If trauma is present, radionuclide bone scanning may be useful to exclude occult fractures of the ribs or sternum. If no trauma is present, bone density testing to rule out osteoporosis is appropriate, as are serum protein electrophoresis and testing for hyperparathyroidism. Based on the patient’s clinical presentation, additional testing may be warranted, including a complete blood count, prostate-specific antigen level, erythrocyte sedimentation rate, and antinuclear antibody testing. CT and magnetic resonance imaging of the thoracic contents, soft tissues, and adjacent organs are indicated if an occult mass or significant trauma to the thoracic contents is suspected ( Figs. 67.4 and 67.5 ). Electrocardiography, to exclude cardiac contusion, is recommended for all patients with traumatic sternal fractures or significant anterior chest wall trauma. The injection technique described later should be used early to avoid pulmonary complications.
