Causes
The main cause of rib fractures is almost always blunt force trauma to the thorax, whereby the extent and severity of the fractures is related to the severity of the force applied.Rib fractures can occur as a result of fisticuffs, falls, traffic accidents with violent impact on the ribcage, and the like. If there is a previously known reduction in bone density in patients due to osteoporosis or similar diseases, so-called “minor trauma” can also lead to rib fractures. These are very minor external or internal violent influences that would not have led to the fracture under normal bone conditions, such as a severe cough, non-violent contact with the thorax, etc.
The diagnosis of a rib fracture is usually quite easy to make. The main symptom here is the almost always present chest wall pain, which worsens depending on breathing. In the patient survey (anamnesis), younger patients with no change in bone density (e.g. due to osteoporosis) have had blunt force trauma to the thorax in the near past.
In older patients with a known reduction in bone density, a severe cough is sometimes enough to break one or more ribs. If a rib fracture is suspected, an x-ray must always be taken in two planes to confirm the diagnosis and exclude accompanying symptoms such as a pneumothorax. If symptoms are present, concomitant diseases such as vascular injuries, nerve injuries, and injuries to the trachea must be excluded.
These can manifest themselves as blood loss, bleeding into the lungs with haemoptysis, sensory and/or motor deficits of the upper extremities or thorax, or breathing problems. Depending on the symptoms, either an imaging of the vessels (angiography) or a CT is indicated. If the fracture is located in the area of the lower ribs, internal organs such as the spleen, liver or kidney may be injured. This can be examined by means of ultrasound diagnostics.
Therapy
The treatment of rib fractures is adapted to their severity. If the patient has a simple rib fracture without major restrictions and complications, “conservative” therapy is usually sufficient. Here, the patient is adjusted with painkillers so that breathing and the unavoidable daily movements no longer represent a burden.
Of course, if a rib fracture exists, no sports should be practiced and large movements, especially lifting heavy objects and loads, should be avoided. To avoid reduced ventilation of individual lung areas, targeted breathing training should be carried out by forced exhalation against resistance under pain therapy. This is part of the standard physiotherapeutic repertoire.
If pneumonia does occur, antibiotics and anti-inflammatory drugs are used to treat it. If a hemato- or pneumothorax develops due to injury to vessels or the lung skin, the accumulated blood or air must be drained off by means of a drainage. A drainage is a tube system connected to a vacuum pump that is inserted into the thoracic wall and sucks air or blood out of the so-called pleural gap.
The drainage is created in the manner of Bülau or Monaldi. A Bülau drainage is placed in the 4th or 5th intercostal space (inter-rib space) in the middle axillary line (in the middle of the armpit). Here the thorax is opened with a small hole, a tube is inserted into the chest wall, the inner end is placed towards the head (in case of a pneumothorax, because air collects at the tip of the lung) or diaphragm (in case of a hematothorax, because blood collects at the base of the lung) and the tube is fixed to the chest wall with a suture.
In case of a drainage according to Monaldi, the access is placed in the second intercostal space in the medioclavicular line. This is the vertical extension of the center of the clavicle. This site is more easily accessible and the diameter of the access is smaller, which means less trauma for the patient but is less effective.
Therefore, the standard procedure is the Bülau drainage. If there is a pneumo- or hematothorax, regular x-rays of the affected area must be taken to monitor the progress. In rare, severe cases of serial rib fractures, there is also an indication for acute surgery. This is the case when the broken rib injures an internal organ, there is heavy bleeding, the lung is injured by a rib fragment, there is a severely displaced fracture, or there is an unstable thorax (see above).Here, the thoracic wall is stabilized by osteosynthesis, i.e. the ribs are brought back to their original position and connected and stabilized with metal. Injuries to internal organs or larger vessels require special treatment, usually the injured areas are closed by means of special suture techniques.
