Definitions and Epidemiology
Acute chest trauma to the rib cage can result in rib fractures. Because in children the bones of the rib are less likely to fracture, complete fractures may be rare. The ribs in general are exposed with very little soft tissue covering. Contact sports place the young athlete at greater risk. Also, sports with missiles and sticks have potential to cause rib fractures.
In younger children, the ribs contain more cartilage and less bone. This places children at relatively increased risk of cartilage and soft tissue injury than fractures. Acute fractures of the lower ribs can result from direct blunt trauma to the chest wall in contact sports like football, hockey, and rugby. High-impact trauma such as automobile, motorcycle, or bicycle accidents result in multiple rib fractures. Chronic repetitive stress of upper body muscles, as in weightlifting, throwing, rowing, and serving sports can result in stress fractures. Forceful contraction against resistance can cause avulsion fractures of the ribs. Traction of the external oblique muscles used in throwing and batting can cause avulsion fractures of the floating ribs.1 Because children have relatively more elasticity, chest wall injuries are less common than their adult counterparts.2 First rib fractures can occur as a result of a fall on an outstretched hand (Figure 37-1). Isolated fractures of the upper four ribs are rare since they are protected by the shoulder complex.
First rib fracture seen in the healing state with callus formation.
The athlete may report feeling of a “pop” or “the wind is being knocked” of him or her. Fractured ribs cause pain with deep inspiration, coughing and sneezing. The deformity of the fractured rib may be palpable, associated with localized tenderness and crepitus. There may be localized swelling and ecchymosis. Because significant energy is required to fracture ribs, this intense energy can result in associated deep organ injury. If the upper ribs are involved, the physician should carefully examine for lung, heart, esophagus, or great vessel injury. If lower ribs are involved, the athlete's abdomen, back, and flank should be examined for associated liver, spleen, gastrointestinal, or kidney injury.2
Chest x-ray may not only identify rib fractures, but also show the presence of hemothorax or pneumothorax. Rib films should be requested if multiple fractures are suspected. Because the ribs are often difficult to fully evaluate on plain films, a CT scan may show rib fractures more clearly than plain x-ray. The CT scan will be even more beneficial in evaluating underlying organ injury in case of multiple rib fractures or when associated complications are suspected.