Pain, Signs, and Symptoms Associated with Rib Fractures
Primary Pain Characteristics
Rib fractures cause severe, sharp chest wall pain that is significantly worse with movement than at rest, with movement-evoked pain scores averaging 2.3 points higher than resting pain scores on a 0-10 scale. 1
- Pain is localized to the site of fracture and worsens with deep breathing, coughing, or any chest wall movement 2, 3
- Movement-evoked pain is the hallmark feature, consistently higher than resting pain in 79% of patient hospital days 1
- Pain severity directly correlates with opioid requirements, with higher movement-evoked pain scores associated with increased morphine milligram equivalents 1
Location and Distribution Patterns
- Mid to lower ribs (ribs 3-10) are most commonly affected, with the 10th rib being the single most frequently fractured 4
- Fractures of ribs 3-10 tend to be more symptomatic due to greater mobility during respiration 5
- First rib fractures and floating rib fractures (ribs 11-12) represent unique injury patterns, often from avulsion forces during vigorous muscle contractions 6
Clinical Signs and Physical Findings
- Point tenderness at the fracture site detected on physical examination 4
- Visible or palpable chest wall deformity in cases of significant displacement 5
- Paradoxical chest wall movement in flail chest (≥2 consecutive ribs each fractured in ≥2 places) 5
- Widening of rib spaces may be visible on imaging, particularly with costal margin rupture 4
- Subcutaneous emphysema present in 2.2% of cases 7
Respiratory Symptoms and Complications
Splinting behavior is the critical pathophysiologic consequence, where pain limits deep breathing and leads to a cascade of respiratory complications 2, 3:
- Shallow breathing and hypoventilation due to pain-related splinting 1, 2
- Impaired ability to cough effectively and clear secretions 2, 3
- Progressive atelectasis from inadequate lung expansion 2, 3
- Each additional rib fracture increases pneumonia risk by 27% in elderly patients 2
- Shortness of breath or difficulty breathing, particularly with exertion 8
- Low oxygen saturation (SpO2 <90%) indicates high-risk patients 5
Associated Injuries and Complications
Pulmonary complications are common and include 7:
- Pneumothorax in 37.2% of cases 7
- Hemothorax in 26.8% of cases 7
- Hemo-pneumothorax in 15.3% of cases 7
- Pulmonary contusion in 17.2% of cases 7
- Flail chest in 5.8% of cases 7
Risk Factors for Severe Symptoms
Elderly patients (>60 years) experience significantly worse outcomes, with each rib fracture increasing mortality risk by 19% 2:
- Age >60 years is a major risk factor for complications 5
- Presence of 2-3 or more rib fractures increases complication risk 5
- Displacement >50% of rib width significantly increases long-term pain 5
- Pre-existing chronic respiratory disease or smoking history worsens outcomes 5
- Anticoagulation therapy increases bleeding complications 5
Functional Impact
- Only 59% of patients return to work at 6 months, indicating substantial long-term disability 2
- Chronic pain, deformity, and respiratory compromise can persist for up to 2 years post-injury 9, 5
- Quality of life remains reduced for up to 2 years in some patients 5
Warning Signs Requiring Immediate Attention
Seek emergency care for 8:
- Worsening shortness of breath or respiratory distress 8
- Fever above 100.4°F (38°C) suggesting pneumonia 8
- Productive cough with yellow, green, or bloody sputum 8
- Chest pain different from the rib pain, especially with shortness of breath or dizziness 8
- Confusion or significant change in mental status 8
Common Pitfall
Undertreatment of pain leads directly to splinting, shallow breathing, poor cough, atelectasis, and pneumonia 9. Movement-evoked pain assessment is superior to resting pain scores for guiding adequate analgesia 1.