The diagnosis | The rib fracture

The diagnosis

The diagnosis of a rib fracture is made by the x-ray image. For this purpose, the chest must be x-rayed in two planes. Individual non-displaced rib fractures can sometimes only be detected after days.

If the symptoms remain the same, it is recommended to take a control x-ray (so-called comparative x-ray). If the rib is broken, the bone can injure a lung. As a consequence, the affected lung may collapse.

This clinical picture is called pneumothorax and should be excluded by a specific X-ray examination during exhalation. To exclude further injuries to internal organs, a sonography (ultrasound examination) can be performed. This can determine whether there is fluid in the lungs, e.g. as a result of a pulmonary hemorrhage (pleural effusion) or if the spleen, liver and/or kidney have been injured.

If a heart injury is suspected or if a serial fracture of the ribs is present, an ECG should be written. In the case of a serial rib fracture, computer tomography (CT) may be useful for an overall assessment. A clinical diagnosis can be made before the above-mentioned diagnostic tools such as X-ray thorax are used.

For this purpose, the doctor palpates (= technique of clinical examination in which body structures can be palpated with one or more fingers) the area where the fracture is suspected. Palpation can cause severe pain, but it is possible to palpate the fracture. However, this is not always necessary, as there are also rib fractures in which there has been no palpable displacement of the bony structures.

However, the findings can be confirmed by the presence of pain and crepitations. The term crepitations describes the audible crackling sound that is produced when the bone fragments rub together. In addition to palpation, the clinical examination also includes listening (ausculation).

A broken rib is considered to be the traumatic cause of a pneumothorax. The broken rib injures the pleura, which consists of two lung sheets. Air can then enter the so-called pleural gap between the two lung leaves.

The result is a collapse of the affected lung because the adhesion of the two pleural leaves has been lost.If the rib fracture has indeed caused a pneumothorax, the examiner would hear a weakened to cancelled breathing sound in this case. The X-ray thorax is considered a standardized examination method and is one of the basic diagnostics for rib fractures. Here, x-rays are taken from the area of the ribcage.

These are taken in 2 planes, i.e. once the body is radiographed from the back to the front and a second time from the side. This is a radiodiagnostic overview image. If a more precise localization is known in advance or can be determined after a general view, a target radiograph is useful.

In addition, the X-ray thorax also allows an assessment of the lungs and heart. If a pneumothorax caused by a rib fracture is suspected, a functional x-ray, in which the x-ray is taken during exhalation, can be helpful. In addition to the existing x-ray, it may be that a second x-ray is indicated.

The reason for this may be the persistence of pain or other complaints. This x-ray is then also called a control x-ray. Sometimes the rib fracture is not detected in a first X-ray immediately after the event.

However, if there is a suspicion, a kind of comparison image can be taken a short time later. It is worth mentioning that the X-ray of the thorax alone often does not allow a clear distinction to be made from a rib contusion, so that ultrasound images are taken for better differentiation. More information on this topic can be found here: X-ray of the thorax.

Sonography is another diagnostic tool. Here, ultrasound can be used to visualize and evaluate organic tissue. A sonography is indicated if there is a suspicion that a rib fracture has affected surrounding structures in the chest and abdomen, so that internal bleeding can be detected.

In the worst case, a broken rib can also damage the heart. In order to rule out an injury, an ECG (= electrocardiogram) can be written in addition to the sonography. In the case of serial rib fractures, a CT (= computed tomography) is also often performed to make a diagnosis.

Although this is also an X-ray, a CT is more complex because it produces many individual cross-sectional images. This cross-sectional imaging method also allows the assessment of soft tissue in addition to the bony structure and is therefore used when the severity or characteristics need to be determined more precisely. The non-displaced rib fracture can be treated conservatively with painkillers such as ibuprofen or Tramadol (Tramundin®) or Novalgin.

If a irritable cough is present, it should also be attenuated with medication. Paracodein drops, for example, are suitable for this purpose. In the case of gentle respiration, care must be taken to ensure that no infections develop as a result of the reduced ventilation.

In the case of a serial rib fracture, the oxygen content in the blood should be measured to check that the oxygen supply is ensured. If a lung (pneumothorax) has collapsed, it must be unfolded again at short notice. For this purpose, a small tube (drainage) is inserted from the outside into the lung, more precisely into the pleura.

A vacuum (25 – 30 cm H20), which is applied to the suction drains (tube), allows the air that was incorrectly introduced into the pleura to escape and unfold the lung. This is a minor surgical procedure. Which painkilling medication is used depends on the extent of the injury or whether one or more ribs (serial rib fracture) are broken.

In most cases, so-called NSAIDs (non-steroidal anti-inflammatory drugs) such as Diclofenac or Ibuprofen are sufficient to relieve the pain. In the case of serial rib fractures, drugs from the opiate group are used because of the usually stronger pain. In addition, a blockage of nerves can be helpful, which can result in complete freedom from pain for a few hours.

In this procedure, a local anesthetic is injected into the area of the nerves that supply the ribs. This can be done once or several times. Under certain circumstances, the application of a kinesiotape or a therapeutic adhesive bandage can be useful.In most cases, however, the surrounding musculature as well as the bones provide sufficient stabilization of the ribcage after a rib fracture.

Nevertheless, many patients have had good experiences with kinesiotaping. These special tapes follow every movement without any problems and ensure improved blood circulation as well as increased lymph drainage in the applied area. Nowadays, plaster casts and other supporting bandages are no longer used because they restrict the mobility of the chest and lungs.