Sternal and Rib Fractures

Sternal fractures are usually associated with direct blunt traumatic injury to the chest sustained in a motor vehicle crash, but stress fractures may also be encountered. Sternal fractures are painful injuries resulting in decreased respiratory excursion and pulmonary atelectasis, so outpatient management should consist of adequate analgesia and incentive spirometry. Sternal fractures may be associated with acute life-threatening intrathoracic injuries such as cardiac contusion, mediastinal injury and bleeding, aortic injury, flail chest, pneumothorax or hemothorax, pulmonary contusions and lacerations, and compression fractures of the ribs and thoracic spine. Because of the high morbidity and mortality of concomitant injuries, a high index of suspicion should be held for associated injuries when sternal fracture is diagnosed.

  • Patients with isolated rib fractures who are unable to cough and clear secretions adequately should be considered for admission for 24-hour observation.
  • Consider admission for patients with underlying lung disease or decreased pulmonary reserve.
  • A lower threshold for admission of older persons with isolated rib fractures is warranted because of their higher incidence of hypoventilation, hypercapnia, atelectasis, and pneumonia.[6]
  • Specifically in the age group 65 years and older, consider admission for patients age ≥85 years, or with initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 or more unilateral rib fractures, or pulmonary contusion.[6]
  • Admission may also allow for observation for occult intra-abdominal organ injury.
  • Patients being admitted should have good pain control and be given an incentive spirometer to prevent pulmonary splinting and its resultant complications.[31]

Complications of rib fracture may include the following:

  • Respiratory failure: The alteration in chest wall mechanics due to multiple rib fractures increases the work of breathing and the patients with multiple rib fractures are at risk for pulmonary fatigue. Respiratory failure can be due to the chest wall injury (eg, flail chest) but is more commonly due to an underlying pulmonary contusion or development of nosocomial pneumonia, especially if superimposed on a preexisting pulmonary condition.[38]
  • Hypoventilation
  • Hypercapnia
  • Hypoxia
  • Atelectasis
  • Pneumonia: Pneumonia is one of the most common complications associated with rib fractures. Pneumonia rates vary depending on the number of fractures and age of the patient. The incidence of pneumonia for all patients hospitalized with one or more rib fractures is about 6%.[38]
  • Damage to underlying visceral organs
  • Pneumothorax (immediate or delayed)[35]
  • Hemothorax (immediate or delayed)[35]
  • Retained hemothorax: Retained hemothorax refers to the presence of blood/clot in the thoracic cavity that persists in spite of thoracostomy drainage. The risk of empyema is increased in patients with retained hemothorax.[39]
  • Aortic injury (immediate or delayed)[40]
  • Pulmonary contusion
  • Intra-abdominal organ injury[18]

Fractures of the first rib have often been associated with serious head injury, cervical spine injury, delayed subclavian vessel thrombosis, aortic aneurysm, tracheobronchial fistula, thoracic outlet syndrome, and Horner syndrome.[3]

(Horner syndrome is a combination of signs and symptoms caused by the disruption of a nerve pathway from the brain to the face and eye on one side of the body.Horner syndrome is the result of another medical problem, such as a stroke, tumor or spinal cord injury.

A small percentage of rib fractures do not heal even though a fibrous capsule may envelope the fracture. A nonunion may present months to years after injury and can cause discomfort with respiration due to movement of the fracture site. Some patients find the respiratory restriction due to pain quite disabling.Contributor Information and Disclosures

Author

Sarah L Melendez, MD Clinical Assistant Instructor, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center and Kings County Hospital Center
Sarah L Melendez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, FACEP Associate Professor of Emergency Medicine, Residency Program Director, Vice-Chair for Education, Department of Emergency Medicine, University of Kentucky-Chandler Medical Center
Christopher I Doty, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Specialty Editor Board

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Additional Contributors

Laurie K Mahoney, MD, FAAEM Attending Physician, Department of Emergency Medicine, Long Island College Hospital, Brooklyn

Laurie K Mahoney, MD, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, and American College of Emergency Physicians

Disclosure: Nothing to disclose.

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Aortic injury is closely associated with a widening of greater than 8 cm measured at the widest points of the mediastinum on an upright anteroposterior chest radiograph.

Normal sonogram of the anterior chest wall using a 7.5-MHz linear transducer. The double arrows show the short-axis view of a rib, with its hyperechoic margin and posterior acoustic shadowing. P denotes the "pleural line" that is also hyperechoic and that should not be mistaken as the rib margin.

Long-axis view of a fractured left third rib of a patient using a 12-MHz linear transducer. The disruption of the hyperechoic cortical alignment is shown by the arrows.

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Sternal and Rib FracturesQUIZ

1. With which type of trauma are sternal fractures associated?

a. Pentrating

b. Blunt

c. Thermal

d. Blast

2. Patients being admitted for sternal and/or rib fractures should be given

a. An incentive spirometer and pain analgesia

b. A rib corset

c. An ace wrap around the chest

d. All of the above

3. Pneumonia is one of the most common complications associated with rib fractures.

a. True

b. False

4. Other diagnoses to look for in patients w/ sternal and/or rib fractures are

a. Pneumothorax

b. Hemothorax

c. Pulmonary contusion

d. All of the above

5. Sternal fractures are painful injuries resulting in decreased respiratory excursion and pulmonary atelectasis, management should consist of adequate pain medication and incentive spirometry.

a. True

b. False