Most isolated rib fractures are diagnosable through a clinical exam. Typically, patients will provide a history of recent blunt or penetrating thoracic trauma and pain at that site. They may also exhibit decreased ability to perform full inspiration due to pain. The physical exam may reveal chest wall bruising, along with bony tenderness to palpitation or crepitus. Any vital sign abnormalities such as hypoxia, tachypnea, or significant respiratory distress should undergo further evaluation of other possible injuries such as pneumothorax, hemothorax, cardiac and pulmonary contusions. Lower rib segment injuries should undergo assessment for kidney, liver, and spleen. Any patient with paradoxical chest wall movement or suspicion for multiple rib fractures should be evaluated for flail chest and managed accordingly.

Rib fractures can be diagnosed clinically based upon history and physical exam without imaging. Dedicated rib x-ray series are typically not necessary due to the benign clinical course of isolated rib fractures. If there is suspicion for multiple rib fractures or significant trauma with underlying organ damage, imaging can be the next step. However, chest radiographs are limited and can only diagnose about 50% of isolated rib fractures.[9] Point-of-care ultrasonography can reliably detect rib fractures along with complications of rib fractures such as pneumothorax.[10] Chest computed tomography (CT) scan is the gold standard of detecting rib fractures, although the fractures detected may not be clinically significant. The utility of chest CT during evaluation has more importance in the general assessment of trauma for other injuries.

For simple, isolated rib fractures, conservative therapy is usually adequate which includes appropriate analgesia, rest, and ice. The use of an incentive spirometer should be encouraged to prevent pulmonary atelectasis and splinting. Intercostal nerve blocks can also be applied to aid in pain control.[11] Rib taping is no longer the recommended treatment as it can impede inspiratory effort. When conservative management fails or for more severe rib fractures, surgical stabilization can be an option. Typical indications for surgical management include rib fracture nonunion, chest wall deformity or defect, refractory rib fracture pain causing respiratory failure, and flail chest.[12] If surgery is necessary, earlier operative intervention leads to better outcomes and also reduction or avoidance for mechanical ventilation.[13]  Additionally, any other underlying injuries such as pneumothorax or hemothorax should be appropriately managed with insertion of a chest tube if indicated.

• Rib and chest wall contusion
• Diaphragmatic injury
• Hemothorax
• Pneumothorax
• Sternal fracture
• Pulmonary contusion
• Cardiac contusion
• Clavicular fracture
• Flail chest
• Scapular fracture
• Pneumomediastinum

Depending on the severity of the trauma sustained and degree of pain, rib fractures may be managed either outpatient or inpatient. Isolated rib fractures tend to heal well and do not need any further interventions beyond pain control, rest, and ice. Multiple rib fractures, displaced rib fractures, or those with underlying concomitant injuries may require inpatient monitoring for respiratory failure or surgical correction. Elderly individuals with rib fractures tend to have a higher mortality rate than younger individuals and may require closer monitoring. 

The most severe complications related to rib fractures are the flail chest and damage to the underlying structures. Solid organ injuries associated with rib fractures include liver injuries and splenic injuries. Typically, the higher the rib fracture is within the thoracic cage, the more likely it is to cause a liver or splenic injury.[14] Particular attention needs to be paid for the patient's respiratory status, as rib fractures may cause the patients to go on and develop acute respiratory failure due to poor respiratory efforts and may need mechanical ventilation and surgical stabilization.

Given that rib fractures in the elderly are associated with higher mortality and morbidity, particular attention and resources need to be directed towards fall prevention to reduce the incidence of rib fractures. Studies show that an interdisciplinary team can significantly reduce the risk of falls in the elderly and therefore, clinicians and hospital staff should receive training on how to provide the necessary tools and resources needed to prevent falls.[15]

As with all significant trauma, a team of trained and dedicated professionals including emergency physicians, trauma surgeons, emergency and ICU nurses is requisite for initial evaluation, management, and stabilization. Early identification of potential patient decompensation should receive attention as a team, and possible interventions such as intubation, chest tubes, thoracotomies should be a team discussion to achieve optimal patient care and clinical results. [Level V] For insignificant trauma and simple rib fractures, patients can be safely discharged after evaluation.