Rib, Fractures

Background: Thoracic trauma often involves multiple organ systems and several anatomic regions. Serious chest trauma results in injury to the sternum; the ribs; and the heart, aorta, and lungs. Because radiographs can depict bony trauma, rib fractures are among the most commonly identified injuries to the chest. Injury to the chest wall may involve the pleural space, the lungs, the extrapleural space, the mediastinum, the heart and great vessels, and the spine and shoulders. The location of specific rib fractures is an important indicator of related injury. Rib fractures can be studied as 3 distinct patterns according to their location (see Image 15): (1) Fractures of the first rib and fractures of the second to fourth ribs, (2) fractures of the fifth to ninth ribs, and (3) fractures of the 10th to 12th ribs. These 3 distinct patterns of rib fractures represent unique pathophysiology and associated morbidity.

Pathophysiology: The most common cause of rib fractures is blunt trauma to the chest wall, which results in a sudden deformity of the semirigid chest wall. Injuries due to motor vehicle accidents and severe crush injuries often result in 1 or more rib fractures. Children seem less vulnerable to rib fractures than adults are because of the elasticity of their thoracic cage. Rib fractures in children who are not involved in a motor vehicle or pedestrian accident may be associated with child abuse. The frequency of fractures increases with increased brittleness of the chest wall, which increases with age. In elderly or chronically ill patients, rib fractures may occur with severe coughing or hard straining and are truly stress fractures. Other less common causes of rib fractures include gunshot wounds and other penetrating wounds of the chest (see Images 33-34). With normal respiration, the sternal ends of the ribs rise and fall, while the vertebral ends remain fixed. The ribs are elevated with the synchronous contraction of the intercostal muscles. This muscular contraction elevates only the sternal ends, which moves the sternal ends of the ribs up and away from the vertebral column to increase the anteroposterior (AP) distance. Changes in thoracic pressure generate pressure gradients necessary for air movement into and out of the lungs. The process of breathing requires the use of both bony structures and accessory muscles; therefore, fractured ribs reduce this dual action and reduce the volume of air that flows into and out of the lungs. Rib fractures can compromise ventilation by causing pain, which can prevent proper ventilation and coughing. This impairment may result in atelectasis, retained secretions, and pneumonia. Multiple rib fractures can cause flail chest, which may result in ventilatory insufficiency due to ineffective respiratory action. Broken ribs can penetrate the lungs and pleura, resulting in a

hemothorax or a pneumothorax. In special clinical circumstances, rib fractures may occur without the effects of acute injury. Stress fractures of the ribs have been associated with repetitive mechanical movement of the upper extremities, as seen in the sports of rowing and golf. The occurrence of stress fractures among rowers has been reported to range from 6.1% to as high as 12%. Rib fractures may occur in older patients after coughing and are stress fractures. Spontaneous pathologic fractures may occur in metastatic disease and severe metabolic disease such as hyperparathyroidism. Osteogenesis imperfecta results in multiple fractures in the absence of specific focal trauma.

Frequency:

In the US: Rib fractures are estimated to be present in 10% of all traumatic injuries and 14% of all chest wall injuries. The most common injury of the chest is a fracture of 1 or more ribs, including a separation of the costochondral junction. Rib fractures are the most common blunt chest injury in adults. With blunt trauma, the middle and lower ribs are the most commonly fractured. The fifth to ninth ribs are most often fractured.

Mortality/Morbidity:

In one study, Ziegler and Agarwal indicated that patients with 1 or 2 rib fractures had a 5% mortality rate and that patients with 7 or more fractures have a 29% mortality rate. Lung-related morbidity rates of patients with multiple rib fractures are 13-69%.

Race: No important racial differences in the occurrence of rib fractures are reported. Sex: Except for occupational risks related to physical labor and violent sports, rib fractures occur equally in young men and women. More older women than older men tend to have rib fractures. Age:

Children seem to be less vulnerable to rib fractures than adults are because of the elasticity of their thoracic cage. Rib fractures in children who are not involved in a motor vehicle or pedestrian accident may be associated with child abuse and are characteristically seen in the posterior portions of the ribs, unlike those of the adult. Serious accident and injury tends to occur more commonly among young men than in others. Sports-related trauma resulting in rib fractures is more common among young men than young women. The failure to wear safety shoulder and seat belts tends to be associated with young automobile drivers. The frequency of fractures increases with increased brittleness of the chest wall, which increases with age. In elderly or chronically ill patients, rib fractures may occur with

severe coughing or hard straining. Nontraumatic rib fractures are more common among older women who also have osteoporosis. Anatomy: The ribs are relatively flat elastic arches of bone (see Images 1-2). They form a large part of the thoracic skeleton. In general, 12 ribs occur in matched pairs on either side. The number of ribs may vary with the development of a cervical rib or a lumbar rib, or their number may be diminished to 11 as an anomaly and in certain conditions (eg, Down syndrome). The first 7 ribs are connected with the vertebral column behind and with the sternum in front, by means of the costal cartilages. The first 7 ribs are called true, or vertebrosternal, ribs (see Image 5, Images 7-8). Of the remaining 5 ribs, the first 3 have cartilages attached to the cartilage of the rib above; these are the vertebrochondral ribs (see Image 4). The last 2 are free anteriorly. The 11th and 12th ribs are termed floating or vertebral ribs (see Image 7). The ribs vary in directional orientation. The upper ribs are less oblique than the lower ribs. Between each rib is an intercostal space. The ribs increase in length from the first to the seventh. The 12th ribs are generally the shortest. The typical rib includes a head, neck, tubercle, body, and costal cartilage. The shaft (body) makes a posterior curve (angle) and extends anteriorly toward the sternal end for the costal cartilage. The costal groove runs along the inferior surface of the rib. The heads of ribs 1 through 9 articulate with 2 thoracic vertebrae. Each of the upper nine ribs has 2 articular facets by which the articulation occurs. The 10th, 11th, and 12th ribs have a single facet with a single vertebral articulation. The 12th rib has no anterior articulation. The last rib may appear similar to a transverse process of the upper lumbar spine; however, it is identified by its articulation with the 12th thoracic vertebral body (see Image 1). The first, second, 10th, 11th, and 12th ribs present variations that require special consideration. The first rib is the most curved and the shortest of the ribs (see Image 3). The general shape of the first rib is broad and flat. The head of the first rib is small and rounded, with a single articular facet (for articulation with the body of the first thoracic vertebra). It has no angle. The upper surface of the body is marked by the scalene tubercle and the grooves, which transmits the subclavian vein, the posterior subclavian artery and the lowest trunk of the brachial plexus. Behind the posterior groove is an attachment of the scalenus medius muscle. The undersurface is smooth without a costal groove. The anterior portion of the first rib is larger and thicker than the other ribs. The second rib is longer than the first. The second rib follows a similar curvature to the first rib. A minor angle is situated close to the tubercle. The body is not twisted. The body is not flattened horizontally like that of the first rib. The external surface of the second rib is convex. The superior surface of the second rib provides the origin of the lower part of the first and the whole of the second digitation of the serratus anterior muscle. A short costal groove is present. The 11th and 12th ribs each have a single articular facet on the head. They have no necks or tubercles. The distal ends of the lower 2 ribs are pointed at their anterior ends. The 11th has a

slight angle and a shallow costal groove. The 12th rib may be shorter than the first. Each rib (except for the last 2) has 4 ossification centers: a primary center for the body and 3 epiphyseal centers. The 11th and 12th ribs have each only 2 centers. Ossification first begins near the angle toward the end of the second month of fetal life. The sixth and seventh ribs are the first to develop. The epiphyses for the head and tubercle make their appearance between the 16th and 20th years of life, and they are united to the body about the 25th year. The important anatomic relationship of the ribs to the surrounding structures includes the thoracic nerves and the intercostal arteries and veins. The anterior divisions of the thoracic nerves are situated between the ribs except for the 12th thoracic nerve, which passes below the 12th rib. Each nerve is connected with the adjoining ganglion of the sympathetic trunk by a gray and a white ramus communicans. The intercostal nerves are distributed to the thorax and abdomen. No plexus formation is present. The percutaneous distribution follows dermatome patterns. The sternum is made of the manubrium, body and the xiphoid process (see Image 2). The body develops from 4 separate centers. The manubrium is attached to the sternum by a cartilaginous union until advanced age. The manubrium articulates with the clavicle on each side. The angle made by the union of the sternum and the manubrium is the sternal angle. The cartilage of the second rib articulates with the manubrium at the level of the sternal angle. The cartilage of the seventh rib joins the sternum at the junction of the body and the xiphoid. Clinical Details: Fractures of the first rib These fractures are extremely rare and more commonly associated with either multiple rib fractures or life-threatening injuries. Fractures of ribs 1-3 have historically been associated with injuries of the brachial plexus and major vessels. Arteriography should be considered in stable patients with first rib fractures if they have absent or decreased upper-extremity pulses, hemorrhage, and/or brachial plexus injury. Additional criteria for angiography include displacement of fragments and multiple thoracic injuries. Fractures of the first rib imply a violent force. This pattern of fractures may signify injury to adjacent subclavian vein and brachial plexus. Isolated first rib fractures are seen in association with cranial and maxillofacial injuries. Surfer's rib is an isolated first-rib fracture, occurring in surfers performing the lay-back maneuver. Isolated first-rib fractures are probably secondary to avulsion of the first rib by its muscular attachment rather than direct trauma to the rib, which is relatively protected. Fractures of the fifth to ninth ribs Fractures of the fifth to ninth ribs can be single or multiple. Multiple fractures can present as flail chest. Flail chest is present when paradoxical respiratory movement occurs in a segment of the chest wall. This requires at least 2 segmental fractures in each of 3 adjacent ribs, the costal

cartilages, or the sternum. Posterior flail segments are easier to manage because of the strong muscular and scapular support and because of a patient's natural tendency to lie with his or her back against the mattress. An inward displacement of the fracture fragments at the time of injury may lacerate the lung parenchyma and produce a pneumothorax with bleeding into the pleural cavity. Occurrence of pneumothorax and hemothorax may be delayed for some hours to days after the injury. Hemothorax of significant degree occurring with rib fractures usually is a result of laceration of an intercostal artery rather than bleeding from the lung. This bleeding could be life threatening. A spontaneous fracture of a midthoracic rib should alert the physician for the underlying metastases or hyperparathyroidism. Fractures of the lower ribs are commonly associated with visceral injury to the kidneys are the spleen. Associated lumbar and thoracic vertebral spinal injuries occur because of the proximity of the transverse spinous processes to the lower thoracic and upper lumbar spine. Pneumothorax Fracture fragments that lacerate the lung parenchyma can cause bleeding into pleural cavity and a pneumothorax (see Image 13). A pneumothorax is a common sequela of blunt trauma.

The incidence of a pneumothorax is not as high with 1 rib fracture, but it increases as the number of broken ribs increases (see Images 17-18).

In a retrospective study, Miller and Ghanekar found that significant solid organ injury is 3.5 times more common in patients with blunt trauma and a pneumothorax than in those without a pneumothorax. They found that the association of rib fractures with pneumothorax results in a larger number of visceral lacerations by fragments of bone. They further recommend that because a large proportion of pneumothoraces found with CT are not visualized on a portable chest radiograph, one should look for indirect signs of pneumothorax, such as rib fractures and subcutaneous air. Hemothorax The incidence of hemopneumothoraces in patients with rib fractures is 30%. A hemothorax is usually the result of a lacerated intercostal artery. Bleeding from broken ribs usually stops before a sufficient volume is lost and emergency thoracotomy is required. About 400-500 mL of blood may be hidden by the diaphragm on the upright chest radiograph, and 1 L or more may be overlooked on a supine image. The bleeding may be delayed or may recur after several days. In a review by Simon et al, 12 cases of delayed hemothorax were identified, and 92% of these occurred in patients with multiple or displaced rib fractures. The presentation occurred 18 hours to 6 days after the injury.

Eleven of these patients complained of new-onset pleuritic chest pain and dyspnea. The symptoms are similar to those of a pulmonary embolism. Pulmonary contusion In patients with rib fractures, the incidence of pulmonary contusions is 20-40%. The injury is characterized by capillary disruption that results in the presence of intra-alveolar and interstitial hemorrhage, edema, protein, and fluid obstruction of the small airways with leukocyte infiltration. Serial chest radiographs obtained beginning right after the injury show a fluffy infiltrate that progresses in extent and opacity over 24-48 hours. Pulmonary contusions are often a part of a major chest injury that includes 1 or more fractures of the thoracic cage, a pneumothorax, and a hemothorax. The contusions may occur due to the transmission of force through the chest wall with minimal fractures of the ribs or sternum; this mechanism is especially seen in young people. In middle-aged or elderly patients, pulmonary contusions are usually accompanied by multiple rib fractures. Aortic injuries The idea that thoracic cage injuries are predictive of acute traumatic aortic tear is controversial. Lee et al concluded that no clinically relevant correlation exists between these injuries and acute traumatic aortic tear. They also concluded that upper rib fractures are not an indication for aortic angiography. Aortic injury related to blunt trauma is usually due to the transmission of a shearing force at the ligamentum arteriosum. However, case reports describe fractured ribs puncturing the aorta. One case involved a posterior fracture of the left sixth rib that lacerated the aorta 3 days after the trauma occurred. Cardiac perforation may result in both pericardial and periaortic hemorrhage. Flail chest A flail chest is present when a paradoxical respiratory movement occurs in a segment of the chest wall, as a result of at least 2 segmental fractures in each of 3 adjacent ribs or costal cartilages (see Images 14-16). The incidence of flail segments is 10-15% in patients with major chest trauma. More severe injuries, such as closed head injury and intrathoracic injury, are more common with flail chest. Multiple fractures of the upper chest with a dislocation of the clavicle are also associated with extrathoracic lung herniation. However, in most cases, no chest wall defects are present. Flail chest may lead to respiratory failure secondary to the pulmonary contusion and pain during

inspiration. Treatment consists of chest-wall stabilization; reduction of the respiratory dead space; management of the pulmonary contusion; and, most of all, pain control. Epidural analgesics are the pain-management agents of choice. Intercostal nerve blocks may also be used. The extent of pulmonary contusion and whether pain management allows for proper pulmonary toilet determine the need for mechanical ventilation. Surgical stabilization is rarely indicated; however, Lardinois et al found that early restoration of the integrity of the chest wall by using reconstruction plates in anterolateral flail chests may be cost-effective. Abdominal solid-organ injury Low-rib fractures, right-sided rib fractures, female sex, young age, and an elevated injury severity score increase the probability of a liver injury. Low-rib fractures, rib fractures on only the left side, young age, and an elevated injury severity score increase the probability of a splenic injury. In a study by Shweiki et al, the incidence of liver and splenic injuries in their population of patients with rib fractures was 10.7% and 11.3%, respectively. Preferred Examination: The patient's medical history and physical examination findings should suggest the diagnosis. The primary signs and symptoms are a pleuritic-type chest pain and tenderness over fracture site. When 2 or more adjacent ribs are fractured, especially if they are broken in more than 1 place, examination alone should be enough to enable a presumptive diagnosis of a rib fracture. Approximately 50% of all fractures go undetected during screening chest radiography (see Images 9-10). The examination of suspected rib fractures should include the acquisition of erect posteroanterior (PA) and oblique radiographs of the chest (see Image 11). An erect frontal examination of the chest is useful in the detection of a pneumothorax, pulmonary contusion, or pleural effusion. The standard chest radiograph is also useful in the recognition of preexistent or coexistent disease. Each oblique projection is intended to depict the entire rib. The PA chest alone is ineffective in the identification of incomplete or minimally displaced rib fractures. The lower ribs may be obscured by upper abdominal organs. If a lower rib fracture is suggested, an AP radiograph of the lower portion of the chest and upper abdomen centered on the upper lumbar spine radiographic technique is required. The routine radiographic examination of the sternum includes frontal prone and rotated views in an off-lateral projection. Although rib fractures may be seen by using bone window settings on a chest CT scan, an occult rib fracture is not an indication for thoracic CT. If the patient remains symptomatic, a repeat radiograph of the ribs, acquired by using a standard technique, often demonstrates the signs of early healing of a rib fracture. If the identification of occult rib fractures is clinically important, as in a case of suspected child abuse or for medical-

legal reasons, radionuclear bone scanning with technetium-99m DPT is often successful. A delay of several days should be allowed after an acute trauma to increase the sensitivity for a rib fracture with radionuclear imaging. Limitations of Techniques: In obese patients and in older patients with osteoporosis, the evaluation for uncomplicated rib fractures is often difficult to perform by using standard radiographs. Greenstick fractures may not be seen on initial chest radiographs because of the nondistracted nature of the injury. Cartilage fractures and costochondral separations are not seen on routine chest radiographs. Several weeks may pass before such injuries are visible on chest radiographs.

DIFFERENTIALS Aorta, Trauma Child Abuse Hyperparathyroidism, Primary Lung, Trauma Tracheobronchial Tear Vascular and Solid Organ Trauma - Interventional Radiology

X-RAY Findings: The most common radiographic presentation of rib fractures seen is that of a minimally displaced irregular lucent line across the cortex of the involved rib. Secondary findings of rib fractures include a localized extrapleural hematoma, which is seen as a focal pleural opacity. Most rib fractures are better seen on a tangent. Posterior and anterior oblique projections are often necessary to detect minimally displaced rib fractures (see Images 10-12).

A small focal pneumothorax or subcutaneous air (see Images 12-13) may be the only initial radiographic sign. A large pneumothorax may result in the shift of the trachea or other mediastinal structures away from the injury (see Image 17). Fracture of the manubrium may be accompanied by presternal hematoma. Injury to the sternum is best evaluated by using lateral and oblique views centered on the sternum. After calcification, fractures of the costal cartilages may be detected by radiographs obtained in an anterior oblique projection. Widening of the mediastinum suggests the possibility of both aortic injury and associated rib or

sternal fractures. In cases of suspected mediastinal bleeding, a lateral radiograph of the sternum can help to confirm a serious chest injury. Degree of Confidence: Blunt trauma to the chest may result in incomplete or nondisplaced rib fractures. Such injuries may not be visible on the initial radiographs. AP supine chest radiographs often fail to demonstrate rib detail. Approximately 10-15% of rib fractures are not visible on the standard chest image. False Positives/Negatives: AP supine chest radiographs often fail to demonstrate rib detail. False-positive readings for rib fractures are associated with superimposed bowel gas over the lower ribs, resulting in the appearance of a lucent line not the result of a rib fracture. The costalcartilage junction is often misinterpreted as a fracture. Artifacts due to clothing, skin folds, and intravenous (IV) lines can lead to false suggestions of rib fractures.

CAT SCAN Findings: Each thoracic CT examination performed for the evaluation of trauma offers an opportunity to diagnose rib fractures. Direct signs of a rib fracture on an axial CT scan of the chest is the separation of 2 rib fragments with associated sharp edges. The secondary findings related to rib fractures include a hemothorax (see Image 20), pneumothorax (see Image 18), and lung contusion (see Image 19). These are more easily seen on chest CT scans than on chest radiographs (see Image 22). All chest CT scans should be reviewed by using a bone window setting. The application of a bone CT algorithm increases the likelihood of finding fractures. Every effort should be made to decrease movement and breathing-related artifacts. All chest CT scans should also be reviewed by using a window level setting that emphasizes the internal lung detail. The areas contiguous with pulmonary contusions and localized bleeding should be carefully examined for rib fractures as well. With improvements in the resolution of CT scanners, the thoracic spine can be examined for fractures by using chest CT images (see Image 22). Gas in the epidural space can arise via a thoracic spinal fracture associated with a pneumothorax (see Images 22-24). Associated injuries to the internal organs of the upper abdomen should be considered in all cases of lower-rib fractures. Posterior lower-rib fractures are often complicated by splenic injury (see Images 2527). Fractures of the posterior upper thorax may be complicated by associated scapular fractures (see Image 28).

In severe motor vehicle accidents, both anterior and posterior rib fractures may be seen in the same patient (see Image 31). Multiple systemic trauma may lead to prolonged hypotension or hypoxia. Multiple cerebral infarcts may result from cerebral hypoxia or as a complication of direct cranial trauma (see Image 32).

Sternal fractures require special care. A clinically important fracture of the sternum may be seen on just a single axial CT image of the chest (see Image 29). Secondary findings of bleeding in the anterior mediastinum and possible aortic injury are important related patterns (see Image 30). Degree of Confidence: Rib fractures that are seen on standard radiographs are not always present on conventional CT images. However, if 4-mm-thick images are obtained by using a bone technique, nearly all rib fractures can be detected by using CT. False Positives/Negatives: Because the ribs lie in the axial plane, axial CT may not depict fractures that are otherwise easily seen on conventional radiographs. If the axial CT sections are obtained with scan thickness of 8-10 mm, nondisplaced fractures can be missed due to partial volume averaging. Partial volume averaging may occasionally cause a depiction that suggests a rib fracture not present. Anomalies of the ribs that thin, twist, or otherwise distort the ribs further contribute to possible false-positive diagnoses of rib fractures. Small, loculated areas of pneumothorax and hemothorax can occur in the absence of rib fractures. MRI Findings: MRI is not used as a primary means of detecting rib fractures. Displaced lateral rib fractures and rib fractures that are posterior can be detected by using gradient-echo MRI. The primary findings in such cases are the related spinal fractures. The secondary effects of posterior rib fractures may be seen as hemorrhage and edema; these are best seen by using fast spin-echo T2-weighted studies and T2-weighted gradient-echo studies. Degree of Confidence: MRI is not a primary means for the diagnosis of rib fractures. False Positives/Negatives: Breathing motion can cause artifacts, resulting in nondiagnostic MRIs of anterior rib fractures. Partial-volume effects may result in a false suggestion of a nondisplaced rib fracture. ULTRASOUND Findings: Direct visualization of rib fractures is generally not possible with ultrasonography. The presence of a hemothorax can be confirmed with sonography of the pleural space. Degree of Confidence: The primary detection of rib fractures with ultrasonography is not useful. Hemothorax cannot be consistently differentiated from a pleural effusion.

NUCLEAR MEDICINE Findings: Nuclear medicine techniques are useful in the detection of subacute rib fractures as well as costochondral separations. The bone-seeking 99mTc-labeled phosphonates are selectively distributed into the area surrounding healing rib fractures. The dose of 99mTc-medronate is

usually 800 MBq. The agent is administered as an IV bolus. If a localized lesion is present, regional blood flow can be evaluated by using a 3-phase study in which a flow phase, a blood-pool image and delayed static images are obtained. The static images are generally obtained 4 hours after the administration of the agent. A positive result for a rib fracture is represented by a focal area of increased nuclear activity. In the case of a linear fracture, the increased activity is localized to the site of the injury. If a large area of the chest wall is injured, several ribs in multiple locations may demonstrate an increased uptake. Degree of Confidence: On delayed images, increased radionuclide uptake in the area of chest wall trauma indicates a rib fracture in most cases. Lateral, oblique, and single photon emission CT (SPECT) imaging techniques improve diagnostic accuracy. Standard radiographs should be compared with bone scans whenever possible. Positive results with radionuclide imaging require a moderate degree of cooperation from the injured patient. Movement, including rapid breathing, results in poor image quality and decreased sensitivity. A rib fracture is generally seen after a short (12- to 24-h) delay in a young patient. In older patients and in patients with metabolic bone disease, fractures may not be visible until 72 hours after an injury. False Positives/Negatives: Normal costochondral uptake in a child may be intense enough to suggest rib stippling when viewed from a posterior projection. Any disease or lesion of a rib that results in increased bone turnover may result in positive findings in the ribs. False-negative results may occur in patients who have recently received Imferon. High levels of iron in the bone marrow interfere with the normal uptake of bone. Fractures or other lesions of the ribs may not be detected until the iron storages return to normal.

ANGIOGRAPHY Findings: Angiography has a limited role in the evaluation of rib fractures. Complications in multiple trauma may include central vascular injury (aortic tear) and laceration of the subcostal artery. Diagnostic angiography may be helpful in demonstration of vascular injury. Angiograms may show a traumatic pseudoaneurysm or the extravasation of contrast material into the pleural space. Degree of Confidence: Thoracic angiography is both sensitive and specific for traumatic aortic injury. Injury to the subclavian artery may require selective injection into the proximal subclavian artery to make the diagnosis of a traumatic pseudoaneurysm. The use of digital subtraction angiography permits full evaluation of the injured artery without artifacts caused by superimposed bone. False Positives/Negatives: The failure to identify an arterial laceration or pseudoaneurysm is

most commonly associated with motion artifacts, rotation, or poor angiographic technique. Ulcerated plaques within the aortic arch of older patients have been mistaken for aortic trauma. The origin of branch vessels that is otherwise poorly filled has been mistaken for small aneurysms.

INTERVENTION Intervention: Radiologic intervention Radiologic intervention in cases of rib trauma generally represents emergency treatment of the complications of chest-wall injury (pneumothorax) or in the control of hemorrhage. Angiography may be used as a diagnostic technique in cases in which findings in the aortic arch and anterior mediastinum remain in doubt. Treatment Bansidhar et al found that 93% of patients with clinical rib fractures are able to resume their daily activities without disability. As a result, they do not advocate routine follow-up chest radiography in addition to physical examination unless deterioration is evident. Adequate pain control, rapid mobilization, and meticulous respiratory care can prevent respiratory complications. An adequate oral analgesic or an intercostal nerve block plus an oral analgesic should provide reasonable pain relief. Epidural analgesia is becoming the standard of care for pain management in patients with multiple rib fractures. In a study in which morphine patient-controlled analgesia was compared with thoracic epidural analgesia involving bupivacaine and fentanyl, the latter provided more adequate pain control. In another study of the effectiveness of intrapleural analgesia for blunt trauma of the chest wall, this treatment did not significantly differ from placebo. Furthermore, the investigators do not recommend intrapleural analgesia for pain management in patients with rib fractures. Rapid mobilization can include oscillation therapy or body positioning in patients that are on bed rest or intubated. This mobilization can involve the patient's ambulating, sitting up in bed, or getting out of bed to move into a chair. Respiratory care entails incentive spirometry, pulmonary toilet, and even mechanical ventilation, when indicated. In splinting the fractures, adhesive strapping or chest binders should be avoided in all patients but the very young. Medical/Legal Pitfalls:

Multiple injuries often occur in people involved in traffic accidents. Rib fractures are among the most common injuries due to auto accidents, with an occurrence of as high as 60%. Radiography of the chest should be a routine part of autopsy of patients who die of

injuries resulting from traffic accidents.

Although cardiopulmonary resuscitation can be life saving, forceful compression of the chest can result in rib and sternal fractures. Repeated compression after iatrogenic rib trauma has been reported to cause pneumothorax, hemothorax, and laceration of the right ventricle. Rib fractures have been reported among infants after chest physiotherapy. In one report, the indications for chest physiotherapy included bronchiolitis and pneumonia. Among those infants with iatrogenic rib fractures, an average of 4 ribs was broken. The incidence of rib fractures after chest physiotherapy is estimated to be 1 case per 1,000 infants with serious chest disease.

PICTURES Caption: Picture 1. Rib, fractures. The common middle rib consists of the neck that is closest to the thoracic spine with an articular tubercle, the angle of which is a curved portion of the rib, and the distal body.

Caption: Picture 2. Rib, fractures. Central rib viewed from the back. The subcostal groove is best seen when viewed from the back. The costal artery and nerve follow the subcostal groove.

Caption: Picture 3. Rib, fractures. The first rib is one of the upper, specialized ribs. Important features include the attachment of the scalenus medius muscle and the serratus anterior muscle.

A groove for the subclavian artery and vein represent important potential areas of serious injury in fractures of the first rib.

Caption: Picture 4. Rib, fractures. Drawing of the 10th rib. Note that the 10th rib has a single articular facet. No direct anterior connection to the sternum is present. The forms of the 10th, 11th, and 12th ribs are similar.

Caption: Picture 5. Rib, fractures. Typical upper thoracic rib. Each of the upper 9 thoracic ribs has 2 posterior articulations with a thoracic vertebral body above and below and an anterior articulation with the sternum

Caption: Picture 6. Rib, fractures. Drawing of the 12th rib. Note the single articular facet. The 12th rib has no angle.

Caption: Picture 7. Rib, fractures. Frontal drawing of rib cage. Ribs 1-12 demonstrate the variable shape of the upper 9 ribs. The 12th rib does not articulate anteriorly. The sternum comprises the manubrium (M), the body (S), and the xiphoid (X). The ribs articulate with the sternum via the costochondral (CC) junction.

Caption: Picture 8. Rib, fractures. Posterior drawing of the thorax. The ribs are numbered 1-12. The clavicle (C) is often involved in injuries that include rib fractures. The scapula (S) is also subject to the injuries that may result in rib fractures.

Caption: Picture 9. Rib, fractures. Anteroposterior (AP) chest radiograph in a patient who presented with severe chest-wall pain on the left side after a minor fall. No rib injury is

Caption: Picture 10. Rib, fractures. Anteroposterior (AP) radiograph of an elderly female patient with severe chest-wall pain on the left side after a minor fall. Image demonstrates a left lateral rib fracture (arrow) not seen on the standard AP chest radiograph.

Caption: Picture 11. Rib, fractures. Oblique detailed radiograph shows rib fractures not depicted on anteroposterior (AP) chest radiographs. Two rib fractures (arrows) are noted on the standard rib images.

Caption: Picture 12. Rib, fractures. Anteroposterior (AP) chest radiograph demonstrates a lateral lower-rib fracture on the left side (white arrow). An associated left subcutaneous gas pattern dissects along the left chest wall (black arrow).

Caption: Picture 13. Rib, fractures. Semierect anteroposterior (AP) chest radiograph in a patient with a nondisplaced posterior fracture of the 10th rib on the left side. A small, apical pneumothorax (black arrow) is present on the left. Volume loss is present in the left lower lobe (white arrow).

Caption: Picture 14. Rib, fractures. Multiple fractures of the upper chest wall on the left. The first rib is often fractured posteriorly. If multiple rib fractures occur along the midlateral or anterior chest wall, a flail chest may result.

Caption: Picture 15. Rib, fractures. Anteroposterior (AP) supine chest radiograph obtained upon the patient's arrival in the emergency department. The patient had been in a serious auto accident. Although rib fractures are identified along the lateral chest wall on the left side (black arrows),

artifacts caused by superimposed metal related to the transportation bed (blue arrows) obscure visualization of other rib fractures along the chest wall.

Caption: Picture 16. Rib, fractures. Supine anteroposterior (AP) chest radiograph obtained after the removal of metal artifacts along the left chest wall. Multiple posterolateral rib fractures are noted on the left (arrows).

Caption: Picture 17. Rib, fractures. Supine anteroposterior (AP) chest radiograph shows that a right tension pneumothorax has developed. This displaces the trachea to the right (blue arrow). A displaced right lower-rib fracture is present in the right posterolateral aspect of the chest (black arrow).

Caption: Picture 18. Rib, fractures. Axial CT image of the chest in a patient with multiple left posterior rib fractures. A large left pneumothorax is present (arrows).

Caption: Picture 19. Rib, fractures. Axial CT image of chest in a patient with left posterior rib fractures. The left pneumothorax (white arrows) is associated with a displaced posterior left rib fracture (black arrow). Secondary effects on the left lung include a pulmonary contusion and volume loss.

Caption: Picture 20. Rib, fractures. Axial CT image in a patient with trauma to the chest wall on the left, where air (yellow arrow) is noted. A small left pneumothorax (blue arrow) is present. The posterior left lung and the pleural space are opacified due to a combination of a left hemothorax and a left pulmonary contusion.

Caption: Picture 21. Rib, fractures. Supine anteroposterior (AP) chest radiograph demonstrates increased opacity of the lateral upper lobe on the left (arrow). This finding is consistent with a pulmonary contusion after chest-wall trauma and rib fractures on the left.

Caption: Picture 22. Rib, fractures. Axial CT image in a patient with a complex, unstable, thoracic spinal fracture. Multiple rib fractures (white arrows) are shown. The midthoracic spine is fractured (yellow arrow). A large right hemothorax (HT) is present.

Caption: Picture 23. Rib, fractures. Axial CT scan of the lower cervical spine in a patient with multiple rib fractures and an unstable fracture of the thoracic spine. Air has dissected in the epidural space posterior to the cervical dura (arrows).

Caption: Picture 24. Rib, fractures. Sagittal reformatted CT scan of the cervical spine in a patient with multiple rib fractures and an unstable thoracic spinal injury. Epidural gas is noted dorsal in the spinal canal (arrows).

Caption: Picture 25. Rib, fractures. Abdominal radiograph demonstrates moderate gaseous distension. The distended stomach was associated with a hemoperitoneum.

Caption: Picture 26. Rib, fractures. Axial CT image in a patient with both anterior and posterior thoracic injuries. A fracture of the sternum (white arrow) and a posterior left rib fracture (yellow arrow) are present.

Caption: Picture 27. Rib, fractures. Axial CT scan of the lower thorax in a patient with multiple trauma. A lower posterior rib fracture on the left has resulted in a splenic contusion (arrow).

Caption: Picture 28. Rib, fractures. Axial CT image in a patient with a severe thoracic injury. Rib fractures and a complex left scapular fracture (arrows) are present.

Caption: Picture 29. Rib, fractures. Axial CT image of the chest demonstrates a comminuted fracture of the body of the sternum (white arrows). The aorta was intact in this case. Note bilateral posterior pulmonary contusions (yellow arrows).

Caption: Picture 30. Rib, fractures. Axial CT scan of multiple upper-rib fractures on the left side and a traumatic aortic rupture. The contour of the aorta (A) is distorted (arrow) at the site of the aortic rupture. The rib fractures are also associated with a left hemothorax (H).

Caption: Picture 31. Rib, fractures. Axial CT image in a patient with multiple anterior and posterior rib fractures. A liver laceration is present. Air is noted in the subcutaneous space surrounding the left ribs (white arrows). Blood is also noted in the perisplenic space (black arrow). The patient was also treated for a large left pneumothorax. Subcutaneous emphysema is noted on the left side, along the chest wall.

Caption: Picture 32. Rib, fractures. Axial CT scan of the brain in a patient with multiple rib fractures and a tension pneumothorax. Multiple, bilateral cerebral infarcts are present (arrows). The direct injury to the brain was less complicated by hypoxia.

Caption: Picture 33. Rib, fractures. Chest radiograph in a patient who presented with a gunshot wound to the anterior chest wall. Note the pulmonary contusion (arrow). The bullet struck an anterior right rib, resulting in a rib fracture. Other injuries involved the pleura and lung on the right.

Caption: Picture 34. Rib, fractures. Axial CT scan of the chest in a patient with a gunshot wound. Note the comminuted rib fracture (black arrow). A lung contusion is present along the path of the bullet (yellow arrow). A chest tube has been placed to treat the right pneumothorax.