Friday was sunny, Mt Rainier was out (of the rain and clouds) and was calling to Kay and me last Friday. We were the first car up the road to Paradise right behind the ambulance. Maybe this was a bad omen. We got to the parking area, chatted with some overnight campers, and started to walk around looking for winter birds that had been seen in the area recently. Then before I had gone more than 50 yards I slipped on the dreaded black ice and landed on my 400 mm camera lens and my right flank. The camera lens definitely broke, and I’m pretty sure at least one of my ribs did too. I say pretty sure because I have the exact symptoms and signs I see in lots of patients with similar stories when I tell them they have a rib fracture, and unless they have concerning physical findings or symptoms of complications of a rib fracture I sometimes treat them without x-rays to confirm the fracture. My area of injury is in about the right 8th rib area, certainly not in the 1st through 3rd ribs when spine or aorta injuries are more common, and not in the very low ribs when liver injury (right side for me) or lung injury is more common. I’ll discuss this with one of my partners tomorrow, but I may pass on x-rays.
With rib fractures prominent in my thoughts I decided to write about this injury, the common mechanisms of injury, natural course of healing, and complications. For those of you who want to cut to the chase rib fractures are usually caused by blunt trauma, the pain starts to improve after 10-14 days and last a couple of months, and unless there are associated injuries most rib fractures heal without complications.
In the elderly falls from standing position or from a height are the most common mechanisms. In the non-elderly adult motor vehicle accidents are the most common cause. In adolescents and young adults sports or recreational activity injuries and non-accidental trauma are most common, and in young children recreational injuries and non-accidental trauma are common causes. I don’t think of myself as elderly, but this makes me think about the coming reality.
The ribs are bow shaped bones that hook in the back to each of the thoracic vertebra, and in the front to a cartilage that is fastened to the sternum in the upper ribs and to the adjacent ribs in the lower ribs. The one or two lowest ribs are unattached in the front and are the so-called floating ribs. The bow of each rib, fastened in the front and back, is prone to snap when the thorax is exposed to blunt trauma. Most of the time the rib is held in its anatomic position by surrounding structures. The muscles between each rib and the one above and below, the periostium covering of the bone, and the lungs below and muscles, fat and skin above hold the two ends of a broken rib usually serve as an effective splint. Necessarily this splint is not rigid to allow breathing, also allowing the broken ends to move and therefore hurt. There is no practical way to immobilize a broken rib, so they hurt every time the thorax moves. This can also make it difficult to see a rib fracture on x-rays initially. The healing bone is more easily seen as it starts to heal a week or more after the injury.
The pain of a rib fracture is worst when there are forces that cause the fractured ends to move. Breathing hurts, deep breaths hurt more and every cough, sniff or sneeze causes movement and severe pain until the ends of the fracture are healed enough to stick in position.. Very localized pain with movement, cough or sneeze with associated muscle spasm is typical of a rib fracture. When sitting or standing still, breathing quietly, and in a position with no direct pressure over the fracture site the pain of a fractured rib may be minimal.
On exam the pain of a rib fracture is typically reproduced by palpation directly over the fracture site, and by causing movement of the affected rib(s) by compression of the chest from front to back or from the sides.
Acute complications of a rib fracture can be puncturing of the pleura that covers the lung causing a collapsed lung or pneumothroax. There can also be bleeding into the space outside the lung causing a hemothroax, or a combination called hemo-pneumothroax. Associated injury when the trauma is extreme can be ruptured spleen, ruptured kidney, and thoracic aorta any of which can lead to life threatening bleeding. If multiple ribs are fractured, especially if fractured in more than one place, a complication called flail chest can occur. A relatively rare, but very serious associated injury is bleeding into the sac around the heart causing pressure high enough to prevent the heart from filling between heartbeats, called pericardial tamponade. This is usually associated with very severe trauma like a high speed motor vehicle accident or other violent injury or a penetrating chest injury like a knife or gunshot wound.
Later complications can include fluid accumulation in the lung spaces from not getting deep breaths or needed coughs to keep the air spaces open. This can lead to pneumonia, needless to say a very painful complication due to the associated coughing. It’s important to take deep breaths several times daily even though it hurts to try to avoid this even more painful complication.
Who should get a chest x-ray or rib x-rays to confirm a rib fracture or look for complications. In the current defensive medicine climate it is often difficult not to get a chest x-ray. When there is a potential third party liability, when any complication is suspected, when the mechanism of trauma is violent enough to be concerned about other internal injuries, or if the patient is not comfortable with not being certain if there is a fracture or not most physicians will order a plain x-ray. This can be negative up to 50% of the time in non-displaced single rib fractures, but can be useful anyway by excluding pneumothroax or other associated acute injuries.
It’s going to be a long next few weeks as my rib fracture heals. I’ll work with my injury putting on a performance Tony Romo would be proud of and hopefully it will help with my empathy as I tell patients to be patient as their conditions run their natural course.