INTRODUCTION — Rib fractures are common injuries, which occur most often following blunt thoracic trauma but can also result from severe coughing, athletic activities (eg, rowing, swinging golf clubs, throwing), and nonaccidental trauma (ie, child abuse). Concomitant injuries and complications range from mild discomfort to life-threatening conditions, such as pneumothorax, splenic laceration, and pneumonia.

This topic will review the initial evaluation and management of isolated rib fractures, including stress fractures, not involving intrathoracic injury. Discussions of the in-patient management of multiple rib fractures, blunt and penetrating thoracic trauma, and stress fractures generally are found separately. (See "Inpatient management of traumatic rib fractures" and "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults" and "Overview of stress fractures".)

CLINICAL ANATOMY AND PHYSIOLOGY — The chest wall consists of 12 pairs of ribs, the first seven of which articulate both posteriorly with the spine and anteriorly with the sternum (figure 1 and figure 2). Ribs 8 to 10 attach anteriorly to the costal cartilage. The lowest two ribs are "floating" and do not connect anteriorly [1]. Immediately below each rib travels its neurovascular bundle, including the intercostal vein, artery, and nerve.

The first rib is unique in that the scaleni insert onto it, and it therefore is exposed to stresses from the action of these neck muscles. The superior ribs (numbers 1 to 3) are relatively protected by the scapula, clavicle, and soft tissue, while the inferior "floating" ribs are relatively mobile. Therefore, the more vulnerable middle ribs (numbers 4 to 10) are most susceptible to injury from blunt trauma. Fractures of superior ribs reflect trauma involving significant force and the potential for injury to major vessels and lung parenchyma.

The ribs act as a unit during respiration, moving in the anterior-posterior (AP) and coronal planes. This concerted rib motion, in addition to the actions of the diaphragm and the intercostal muscles, enables inspiration (by increasing intrathoracic volume and decreasing intrathoracic pressure) and expiration (by decreasing intrathoracic volume and increasing intrathoracic pressure).

MECHANISM OF INJURY — Most rib fractures are caused by direct trauma to the chest wall. This can occur from blunt (eg, motor vehicle crash) or penetrating (eg, gunshot) trauma. A single blow may cause rib fractures in multiple places. Traumatic fractures most often occur at the site of impact or the posterolateral bend, where the rib is weakest. Both displaced and nondisplaced fractures can be seen in adults and children [2]. Due to the greater pliability of children's ribs, greater force is required to produce a fracture. (See "Initial evaluation and management of chest wall trauma in adults".)

Rib fractures may be pathologic. Cancers that metastasize to bone (eg, prostate, breast, renal) frequently become apparent in a rib. Ribs are relatively thin compared with major long bones and are more likely to fracture when invaded by a metastatic lesion. (See "Epidemiology, clinical presentation, and diagnosis of bone metastasis in adults".)

In the absence of significant trauma (eg, motor vehicle collision), rib fractures in infants are extremely uncommon. Clinicians must investigate possible nonaccidental trauma (ie, child abuse) when such fractures are discovered. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Thoracic injury'.)

Ribs can sustain stress fractures from repetitive minor trauma [3-5]. Stress fractures may be seen in patients with a chronic cough [6,7], but also in athletes, particularly rowers and golfers, as well as throwers and others [5,8-13]. Because of the unique forces exerted on the first rib, it is susceptible to stress fractures in throwing athletes [8,14]. (See 'Clinical anatomy and physiology' above and "Overview of stress fractures".)

CLINICAL PRESENTATION AND EXAMINATION

General fractures — Patients with rib fractures who are not victims of high-energy trauma typically describe a history of minor or moderate blunt trauma to the chest wall. Often, they can localize the pain to one or two ribs, and they describe an injury that corresponds with the area of discomfort. The patient can frequently reproduce or exacerbate the pain by taking a deep breath.

Examination findings strongly suggestive of rib fracture include point tenderness on a specific rib or focal tenderness caused by compression of the ribcage distant from the site of pain. Bony crepitus and ecchymosis may be present. Bony crepitus is an auscultated click caused by movement of the rib fracture and can be heard with a stethoscope placed over the fracture site.

Clinicians should look, listen, and palpate for evidence of internal injury when examining patients with suspected rib fractures. Signs, such as diminished breath sounds, may reflect splinting from the pain of a simple chest wall contusion. However, they may also reflect the presence of significant injury (eg, pneumothorax, hemothorax, or pulmonary contusion). Pneumothorax would present as diminished breath sounds and possibly air crepitus resulting from subcutaneous emphysema. Pulmonary contusion may cause diminished breath sounds, but if there is blood in the alveoli crackles may be audible. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Pulmonary injury'.)

Rib fractures sustained by patients as a result of more serious trauma are often associated with internal injury. Fractures of ribs 9 through 12 may be associated with intraabdominal injury; fractures of ribs 1, 2, or 3 may be associated with mediastinal injury, particularly to the aorta, and they are associated with increased mortality in some observational studies [15]. More specifically, first rib fractures are associated with greater overall injury severity (Injury Severity Score >15) and life-threatening internal injury (including injuries to the brain, spine, lungs, and pelvis), independent of mechanism, age, or gender [16].

Intrathoracic injury, such as pneumothorax or pulmonary contusion, can occur in association with rib fractures at any level. The risk of intraabdominal or intrathoracic injury increases if two or more rib fractures are present at the same level [17-20]. Fractures of the right lower ribs are more often associated with hepatic injury, fractures of the left lower ribs with splenic injury, and fractures of the posterior portion of the lower ribs with renal injury. The assessment of patients with high-energy abdominal or thoracic trauma is discussed separately. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Thoracic trauma in children: Initial stabilization and evaluation" and "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial management of trauma in adults".)

Flail chest occurs when three or more adjacent ribs are each fractured in two places, creating one floating segment comprised of several rib sections and the soft tissues between them (figure 3 and figure 4). This unstable section of chest wall exhibits paradoxical motion (ie, it moves in the opposite direction of uninjured, normal-functioning chest wall) with breathing and is often associated with significant morbidity from pulmonary contusion, as well as injuries elsewhere. (See "Inpatient management of traumatic rib fractures", section on 'Flail chest'.)

Patients who have impaired consciousness or are victims of high-energy trauma may be unable to localize pain to the chest wall. Clinicians often detect rib fractures in such patients by careful examination of the chest wall and back. In most victims of major trauma, a chest radiograph is obtained in the emergency department (ED) and is the means by which multiple or displaced rib fractures are identified [21]. Although the practice of obtaining chest radiographs in all trauma victims has been questioned [22], it remains common practice. Its role in this setting may be more important for finding associated trauma, such as hemothorax or pneumothorax rather than rib fractures. Nondisplaced rib fractures and those at the costochondral margin are often missed on plain chest radiographs. (See 'Diagnostic imaging' below.)

Stress fractures — Rib stress fractures present with a gradual onset of activity-related chest wall pain, similar to stress fractures of other bones [11,23-25]. Often the pain first occurs only with the inciting activity (eg, coughing, rowing, swinging a golf club, throwing), then progresses to pain with deep breathing or simple movements, such as rolling over in bed or reaching overhead.

DIAGNOSTIC IMAGING

Imaging following trauma

Chest radiographs — Standard posterior-anterior (PA) and lateral chest radiographs are adequate to identify some rib fractures, but overall sensitivity is poor (image 1 and image 2) [15,21,26]. In patients who cannot undergo a PA and lateral radiograph (eg, those with hemodynamic instability or spinal immobilization), an anterior-posterior (AP) radiograph will often suffice (image 3). Chest radiographs enable clinicians to look for a pneumothorax, hemothorax, and other signs of intrathoracic injury, which is the main reason they are obtained.

For patients who have sustained trauma to the torso but do not require admission and will not be studied with a thoracic computed tomography (CT) scan for other reasons, some period of observation and follow-up chest radiographs may be needed, depending upon the clinical circumstances. This scenario is discussed in greater detail separately. (See "Initial evaluation and management of chest wall trauma in adults", section on 'Clinical or radiographic rib fractures'.)

The sensitivity of dedicated rib films for rib fracture (sometimes referred to as a "rib series") is higher because these radiographs use a bone exposure (which entails higher levels of radiation than standard chest radiographs) and include oblique views of the chest wall not included with a standard chest series. However, in the great majority of cases, clinicians can base their diagnosis and management on plain radiographs and clinical findings, and a rib series is unnecessary [27-30]. We suggest obtaining a rib series only if there is high clinical suspicion for pathologic or multiple rib fractures not apparent on plain chest radiographs, detection of additional fractures would alter management, and CT is not available. Clinicians should have a lower threshold for obtaining advanced imaging (typically a chest CT) in elderly patients, who have significantly increased morbidity from multiple rib fractures and are more likely to have pathologic fractures (eg, from metastatic lesions) [31-33]. (See "Geriatric trauma: Initial evaluation and management".)

A rib series is rarely obtained in trauma patients. Those patients suspected of having sustained a significant intrathoracic injury are evaluated with a CT scan of the chest (image 4 and image 5). CT is invaluable for identifying intrathoracic injuries and demonstrates greater sensitivity and specificity for rib fractures compared with plain radiographs. However, the initial screening plain chest radiograph obtained in trauma patients remains a useful tool, and injuries of sufficient magnitude to appear on the screening radiograph may predict subsequent pulmonary morbidity more accurately than CT [34]. Rib fractures of the lower rib cage can be associated with intraabdominal injury and abdominal CT may be useful [35]. The evaluation of patients with possible intrathoracic injury is discussed in detail separately. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults".)

Clinicians should obtain a skeletal survey in infants suspected of being abused. Findings consistent with abuse include the presence of multiple rib fractures in various stages of healing. Imaging studies for rib fractures in the setting of possible child abuse is discussed separately. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Thoracic injury'.)

Ultrasound — While the quality of evidence is limited, the results of several observational studies suggest that ultrasound may be useful in the diagnosis of traumatic rib fractures (image 6 and image 7) [36-39]. Ultrasound appears to have good sensitivity but limited specificity. Perhaps most importantly, ultrasound is an effective tool for evaluating potentially dangerous complications of rib fractures, such as pneumothorax (image 8 and image 9). The use of ultrasound for this purpose is reviewed separately (see "Emergency ultrasound in adults with abdominal and thoracic trauma").

In addition to aiding with diagnosis, ultrasound may help to distinguish between pathologic and traumatic fractures based on appearance, but definitive diagnosis requires further evaluation. (See "Overview of the classification and management of cancers of unknown primary site".)

Chest computed tomography — Chest computed tomography (CT) is not performed for the sole purpose of assessing potential rib fractures. However, rib fractures are commonly identified on CT studies obtained to assess trauma patients for internal injuries. Observational studies of trauma patients show a clear increase in the number of rib fractures identified on chest CT compared to standard chest radiograph, but the clinical significance of these additional findings is generally minimal. As examples, in a retrospective observational study of 589 patients with blunt trauma and a normal plain chest radiograph, chest CT identified a total of 66 rib fractures not seen on the radiograph but only 12 clinically significant injuries [40].

Other techniques — In the past, routine arteriography was recommended for patients with fractures of the first or second rib out of concern for aortic and other mediastinal injury. However, this approach is no longer recommended in the absence of evidence of vascular injury, such as a widened mediastinum on chest radiograph [41].

Imaging stress fractures — Special imaging may be required in some cases of suspected rib stress fracture when there is doubt about the diagnosis or when a definitive diagnosis is required to make decisions about returning to competition [4,24,25]. A bone scan of the chest wall has long been the preferred instrument to diagnose rib stress fractures early in the pathologic process due to its high sensitivity and ease of interpretation (image 10). Such fractures typically are not visible on plain radiographs of the chest until late in their healing, when visible callus is present. The need for imaging will vary based on the clinician's experience managing rib stress fractures.

While magnetic resonance imaging (MRI) is the imaging modality of choice for many other types of stress fractures, bone scan has been preferred for stress fractures of the ribs (if additional imaging is necessary at all) because the oblique orientation of the ribs and the difficulty with numbering them on axial or coronal scanning can make MRI more difficult to interpret. In addition, the detailed imaging of adjacent soft tissues provided by MRI is of lesser importance with rib fractures, and MRI is more expensive.

Nevertheless, MRI is preferred by some due to concern for radiation exposure from bone scan. When MRI is chosen, the study protocol must include appropriately thin sections of the area of concern or a rib stress fracture could be missed. Therefore, it is best to discuss the reason for the MRI directly with the radiologist to ensure that an appropriate protocol is used.

Musculoskeletal ultrasound is increasingly being used as a method for diagnosing rib stress fractures [42].

INDICATIONS FOR REFERRAL — Emergency referral is generally needed because of the injuries that accompany rib fractures. Pneumothorax, liver and spleen lacerations, and pulmonary and cardiac contusions comprise some of the more serious injuries associated with rib fractures sustained in high-energy trauma. Pneumomediastinum and pneumopericardium suggest the presence of major injury. Fractures of the first three ribs generally occur from significant force and may be associated with mediastinal, particularly aortic, injury. Displaced rib fractures likely increase the risk of injury to the lung and proximate intercostal blood vessels.

All patients with superior (first or second rib) or displaced rib fractures, fractures of multiple ribs, or possible internal injuries should be sent directly to the emergency department (ED) for evaluation. Once in the ED, patients who have sustained significant trauma are managed in the appropriate manner, including imaging studies. Disposition is based upon the injuries identified, the risk of delayed presentation of significant injuries (eg, pulmonary contusion, intercostal bleeding), and clinical and social circumstances. (See "Initial management of trauma in adults" and 'Disposition' below.)

INITIAL MANAGEMENT

Analgesia and monitoring — Once significant associated injuries have been evaluated and treated, the cornerstone of rib fracture management is pain control [43-45]. Early and adequate pain relief is essential to avoid complications from splinting and atelectasis, primarily pneumonia. The choice of analgesia depends upon the injury, the clinician's comfort performing nerve blocks with their potential complications, and the ease with which more invasive treatments can be performed. Analgesia for severe and multiple rib fractures and monitoring of admitted patients are discussed separately. (See "Inpatient management of traumatic rib fractures", section on 'Pain control' and "Inpatient management of traumatic rib fractures", section on 'Management approach and initial care'.)

For isolated injuries (ie, single rib fracture), clinicians generally begin treatment with nonsteroidal antiinflammatory drugs (NSAIDs) with or without opioids [46]. For more severe injuries, particularly if ventilation is compromised, admission and invasive treatments, such as intercostal nerve blocks (figure 5), may be needed. (See "Thoracic nerve block techniques", section on 'Intercostal nerve block'.)

Respiratory care, including use of incentive spirometry to prevent atelectasis and its complications, is often important [45]. We do not recommend rib belts or binders because they compromise respiratory function. Studies of rib belts involve small numbers of patients and have reached contradictory conclusions [47,48]. Patients with a rib fracture who are discharged home can perform incentive spirometry intermittently throughout the day, after analgesics have taken effect. Holding a pillow or similar soft brace against the fracture site reduces discomfort while using the spirometer, or when coughing or sneezing.

Disposition — Research pertaining to the appropriate disposition of patients with isolated rib fractures consists largely of retrospective observational studies, and thus published guidelines rely heavily on clinical experience and expert opinion [19,45,49,50]. It is clear that the rate of significant complications associated with rib fractures increases with the number and severity (eg, displacement) of fractures, patient age or frailty, and compromised respiratory function, either acute or chronic due to underlying disease. Significant complications may include pneumothorax, pulmonary contusion, pneumonia, and intercostal hemorrhage. Patients with multiple rib fractures sustained from high-energy trauma are best evaluated at a trauma center and transfer should be arranged expeditiously. An algorithm to assist clinicians with the disposition of patients with isolated rib fractures is provided (algorithm 1). (See "Initial management of trauma in adults".)

Bearing the above concepts in mind, in most cases, we suggest hospitalization for patients with three or more rib fractures. However, the risk of complications varies widely among individual patients, and all patients with isolated rib fractures should be assessed carefully for the adequacy of pain control and signs of respiratory compromise. A lower threshold for hospitalization, and possible admission to an intensive care setting, even for a single rib fracture, is appropriate for patients 65 or older and younger adults considered to be frail, and for patients with any evidence of respiratory decompensation or who are at risk for such due to chronic disease. Evidence of respiratory compromise includes an oxygen saturation below 92 percent when breathing room air and an inability to perform incentive spirometry greater than 15 mL/kg. This approach is consistent with that published by the Western Trauma Association [45].

According to a large, retrospective study, most older adult patients admitted with isolated rib cage fractures do not need intensive care [51]. In this study of just over 5000 patients 65 years of age or older, only 1.1 percent of patients with two or more rib fractures initially triaged to a regular floor bed (n = 3577) developed complications requiring intubation or transfer to an intensive care setting. Factors associated with failure of regular ward management included chronic kidney injury, traumatic pneumothorax, concurrent sternal fracture, drug use disorder, and an oxygen requirement or oxygen saturation below 95 percent while in the emergency department (ED).

Rarely, younger healthy individuals with three (or possibly more) rib fractures but no sign of significant internal injury, having undergone a thorough clinical and radiographic evaluation by clinicians experienced in trauma management, and an appropriate period of observation (we suggest a minimum of six hours of observation, including a follow-up chest radiograph or ultrasound just prior to discharge to rule out pneumothorax) during which they remain well-appearing with no new symptoms or signs, may be discharged from the ED [52-54]. Clinicians must also consider patient comorbidities and clinical and social circumstances when determining disposition. Signs of injuries due to rib fractures (eg, pneumothorax, pulmonary contusion) may be delayed for hours or days, and all discharged patients must be given precise instructions about signs of injury to watch for and told to return to the ED immediately should any such sign appear [55,56]. The guidelines just below for discharged patients with one or two nondisplaced rib fractures apply to patients with three such fractures as well.

Displaced rib fractures likely increase the risk of injury to the lung and proximate intercostal blood vessels [50]. Bleeding from such fractures can be delayed, and admission or close observation and follow-up should be arranged for patients with displaced fractures, depending upon clinical and social circumstances. Multiple case reports indicate that delayed bleeding from intercostal vessels or other injuries can be life-threatening, particularly in older patients [53,57,58]. (See "Geriatric trauma: Initial evaluation and management", section on 'Chest trauma'.)

Patients with one or two nondisplaced rib fractures found on imaging studies, or focal tenderness over one or two ribs but no evidence of fracture on CXR and who are assumed to have a rib fracture, may be treated with analgesics and discharged without a period of observation, assuming there are no other injuries of concern. Appropriate follow-up should be arranged. Patients with clinical or radiographic evidence of one or two rib fractures who are discharged must be warned to return immediately to the ED for any concerning symptoms, such as shortness of breath, increasing pain, or signs of pneumonia (eg, cough, fever). We suggest that such patients be given an incentive spirometer, educated in its proper use, and strongly encouraged to use it frequently in order to prevent atelectasis and pneumonia.

Surgical fixation may be of benefit with some types of rib fractures, particularly those associated with chest wall deformity, flail chest, or symptomatic nonunion. In addition, surgical repair may be needed in cases of nonunion. The appropriate role of surgical fixation is discussed separately. (See "Inpatient management of traumatic rib fractures", section on 'Surgical management'.)

Associated morbidity and mortality, the interventions required for adequate pain control, and additional treatments needed for patients with rib fractures can vary substantially. Therefore, we suggest that institutions develop clear guidelines for the management and disposition of patients with rib fractures to help ensure proper care.  

Treatment of stress fractures — Little published evidence is available to help guide the management of rib stress fractures [59]. In general, rib stress fractures are treated similarly to other low-risk stress fractures. Treatment begins with restriction of the inciting activity for four to six weeks, followed by a gradual return to the activity as tolerated. During rehabilitation, attention should be paid to ensuring proper mechanics and eliminating training errors to avoid recurrence. Clinicians treating rowers will find useful a 2015 guideline and algorithm written by physicians for the British rowing team, which reviews the care of rib stress injuries in rowers [23,24]. (See "Overview of stress fractures".)

FOLLOW-UP CARE — Management and follow-up for patients with multiple rib fractures or rib fractures associated with significant internal injuries is discussed separately. (See 'Disposition' above and "Initial evaluation and management of blunt thoracic trauma in adults".)

Delayed injuries from isolated rib fractures sustained during blunt trauma occur infrequently. Patients should be instructed to seek immediate medical evaluation should they develop difficulty breathing, severe pain, or other concerning symptoms [53,54].

Most rib fractures heal within six weeks. Many patients are able to resume daily activities much sooner. However, patients should be warned that pain from rib fractures can be severe for several days following the injury. (See 'Analgesia and monitoring' above.)

Routine follow-up chest radiographs days after the injury are not recommended [60]. They add little to a careful clinical examination other than cost and should be performed only if indicated by clinical findings (eg, unilateral decreased breath sounds suggesting pneumothorax, persistent pain suggesting malunion or nonunion). A follow-up examination six to eight weeks after the injury is reasonable to assess the patient, if they are unable to return to sports or work by that time. (See 'Return to sports and work' below.)

COMPLICATIONS AND ASSOCIATED INJURIES — Complications from rib fractures correlate with the number of ribs fractured and fracture location. Associated injuries, such as liver or spleen lacerations, mediastinal injury, pneumothorax, hemothorax, flail chest, and pulmonary contusion, may occur, but are uncommon with isolated minor injuries. Complications associated with multiple rib fractures are discussed separately. (See "Inpatient management of traumatic rib fractures", section on 'Rib fracture complications' and "Inpatient management of traumatic rib fractures", section on 'Associated injuries'.)

Complications, such as pneumonia, can occur as a result of atelectasis, caused by splinting from inadequate analgesia. Among older adults, morbidity and mortality are twice that in younger populations, and some increased morbidity is apparent in patients over 45 years old. Delayed complications (eg, pneumothorax, pulmonary contusion, pneumonia) occur, but are rare with minor injuries [61]. Rib fractures rarely go on to nonunion, and not all nonunions require surgery. (See "Inpatient management of traumatic rib fractures", section on 'Morbidity and mortality' and 'Indications for referral' above.)

RETURN TO SPORTS AND WORK — Return to work or sport depends upon the activity involved and the level of pain. Heavy labor and intensive training for athletes with stress fractures are not recommended for the first three weeks. Once there is no longer any pain at rest, the patient can begin to increase their activity level, but this should be done gradually. Most rib fractures heal within six weeks. Many patients are able to resume daily activities much sooner.

Virtually all nonpathologic rib fractures heal well with conservative management. Some patients are able to return to work within a few days, depending on their occupation. One small case series suggests some patients experience prolonged pain and disability [62]. It found that patients with an isolated rib fracture regain pain-free function at a mean of 51 days.

Some athletes engaged in contact sports can return to play as soon as one week after acute injury, provided the fractured rib is protected with a flak jacket or similar device [63]. The jacket should be worn for six to eight weeks.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of acute fracture management".)

●(See "General principles of definitive fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Thoracic trauma" and "Society guideline links: General fracture and stress fracture management in adults" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Rib fractures in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Rib fractures are common injuries that occur most often following blunt thoracic trauma but can also result from severe coughing, athletic activities (eg, rowing, swinging golf clubs), child abuse, and bone metastases. Concomitant injuries and complications range from mild discomfort to life-threatening conditions, such as pneumothorax, splenic laceration, and pneumonia.

●Rib fractures in victims of blunt trauma are generally identified clinically or by chest radiograph. Patients with rib fractures who have not sustained severe trauma typically describe a history of a minor to moderate chest wall injury. Frequently, they can localize the pain to one or two ribs and give a history that is consistent with the area of discomfort. A deep breath typically elicits pain at the fracture site. Rib stress fractures present with a gradual onset of activity-related chest wall pain. (See 'Clinical presentation and examination' above.)

●Standard posterior-anterior (PA) and lateral chest radiographs are adequate to identify most rib fractures. If these studies cannot be readily obtained, a simple anterior-posterior (AP) chest radiograph can provide useful information. Ultrasound may be useful for diagnosis of rib fractures and potential complications (eg, pneumothorax). A skeletal survey should be obtained in infants suspected of being abused. Findings consistent with abuse include the presence of multiple rib fractures in various stages of healing. (See 'Diagnostic imaging' above and "Physical child abuse: Diagnostic evaluation and management".)

●Emergency department (ED) evaluation is needed when rib fractures are accompanied by other major injuries (such as pneumothorax, liver or spleen lacerations, and cardiac or pulmonary contusions), or when such injuries are suspected. Multiple rib fractures correlate more closely with serious intrathoracic and intraabdominal injuries. Fractures of superior ribs (numbers 1 to 3) reflect trauma involving significant force and the potential for injury to major blood vessels and lung parenchyma. Displaced fractures increase the risk of internal injury and delayed bleeding and generally warrant admission.

●We suggest hospitalization for patients with three or more rib fractures in nearly all cases, but a more conservative threshold for admission is appropriate in many cases, particularly in older or frail adults and those at increased risk for pulmonary complications. An algorithm to assist clinicians with the disposition of patients with isolated rib fractures is provided (algorithm 1). (See 'Indications for referral' above and 'Disposition' above.)

●Treatment of rib fractures should be focused on early and adequate pain relief to avoid complications from splinting and atelectasis, primarily pneumonia. To provide analgesia, clinicians most often use nonsteroidal antiinflammatory drugs (NSAIDs) with or without opioids. Intercostal nerve blocks are another effective approach for some patients. (See 'Initial management' above.)

●Rib stress fractures are treated similarly to other low-risk stress fractures. Treatment begins with restriction of the inciting activity for four to six weeks, followed by a gradual return to the activity as tolerated. (See "Overview of stress fractures".)

●Virtually all rib fractures heal well with conservative management. Follow-up chest radiographs are unnecessary, unless indicated by clinical symptoms (eg, new shortness of breath). (See 'Follow-up care' above.)