Rib Injuries

Question: What are the differences, symptoms, severity, and complications of rib injuries, and how much do they hurt?

Ah, ribs. Those grand old things that protect all your most vital organs. What lay-people generally think of as a ribcage aren’t just bones though. They are actually composed of twelve bones on either side of the chest, plus thick, tough cartilage (like in your nose, only stronger), and the sternum (breastbone). All 24 long, curved rib bones attach to the spinal column in the back (backbone), but in the front, only some of them are attached at all. The top seven on either side are attached to costal cartilage which attaches directly to the sternum. The next three pair are attached to costal cartilage which attaches to another cartilage rather than the breastbone, and the bottom two pairs, called “floating ribs” don’t attach in the front at all.

In the above computer modeled ribcage photo, the white areas indicate bone and the golden-yellow areas are costal cartilage. The area circled in pink is a small tip of bone called the xyphoid process, which can be broken off pretty easily. In a living body, there would also be muscles called intercostal muscles in between each long rib bone to connect each bone to the one above or below it.

Types of Injuries

There are three basic types of injuries that can happen to the ribs: Fractured or broken bones, bruised bones, and torn cartilage. “Cracked” ribs are broken ribs – there is NO difference between cracked and broken ribs, however breaks can have varying severity – anything from a little “crack” to a complete break across the entire thickness of the bone. The symptoms for all three are going to be pretty much identical.

• Pain, especially when taking deep breaths, coughing, laughing, bending, twisting, lifting weight, or pressing over the injured area.
• Possibly bruising over the injured area
• Crunching or grinding noises or sensations with movement
• Actual deformities in the shape of the chest over the injured area (a dent, basically)
• Difficulty breathing (either from the pain or as a complication of a fracture – see below)

How do rib injuries occur?

Anything that causes a trauma to the chest can injure the ribs. Contact sports, fighting, car crashes, and CPR are some of the most common causes of damaged ribs. I once had a doc tell me that if you’re doing CPR chest compressions and you DON’T feel ribs breaking, you aren’t doing it right. While not a really good rule of thumb, it is true that CPR chest compressions often result in broken ribs, especially in the elderly and small children. It is important not to be afraid of breaking ribs though, when doing CPR. Most people would rather be alive to complain about the rib pain later.

How are they treated?

In modern medicine, all three injuries are basically treated the same way:

• Rest – avoid anything that makes the area hurt, except breathing.
• Ice, on for 10-20 minute and off for 20-30 minutes. Rinse and repeat.
• Over the counter pain medications – preferably in the NSAID (non-steroidal anti-inflammatory drug) class such as aspirin or ibuprofen because these drugs treat inflammation/swelling as well as pain, unlike tylenol(acetaminophen)
• Deep breathing exercises to prevent pneumonia if breathing is troublesome.

In days past, docs used to apply rib splints or compression dressings (think ace wrap) to help “support” the ribs and prevent them from moving around too much. This decreased the amount of pain associated with breathing and coughing and whatnot, but in turn significantly increased the risk of pneumonia and death as complications. Oops.

We don’t do that so much anymore, although applying some firm, consistent pressure with a hand over the injured area only when coughing or sneezing, or doing something else short term that causes increased pain can be effective at decreasing pain. These days compression dressings and splints are only used in cases that are VERY severe.

What nasty little surprises can my characters expect me to spring on them down the road?

Ah, complications. They do make a story interesting. The complications of rib injuries are going to vary by the injury a bit.

• Pneumonia – All three types of injury can cause significant pain with breathing, encouraging the person to take very shallow breaths. If the person keeps this up for a few days or a couple of weeks, chances are good that the person is going to regret it later, in the form of a solid case of pneumonia. The lungs produce mucous constantly. Kind of ichy, but there’s a good reason for it. Germs, dust, and other nasty things that shouldn’t find a home inside your lungs get trapped in the mucous and coughed up. If you don’t take breaths that fill your whole lungs up with air, over time the mucous can thicken up and “collapse” the air sacs inside the lungs, along with their collected germs. Viola, pneumonia. Symptoms of pneumonia include fever, chills, coughing up stuff from deep in the lungs(usually yellow, tan or green in color), wheezing, and difficulty breathing. If not treated or overcome by the body’s natural immune abilities, pneumonia can quickly lead to blood stream infections (sepsis), shock, and death. Or it can linger around for a long time and cause a gradual worsening or leave permanent damage (short breath, wheezing).
• Punctured lung – this is usually going to show up pretty quickly and only in severely broken ribs (think massive trauma to the chest, like smashing against a steering wheel while not wearing a seatbelt in a 50mph car crash). The space between the injured lung and the ribs will fill up with blood(hemothorax) or air (pneumothorax), squishing the lungs over in the process and making it harder and harder to breath. If there is air moving from the lung into the space, the lungs and eventually the heart will get smooshed over to one side (away from the injury) until they can’t expand anymore and the person basically suffocates and the heart can’t refill with blood to pump anymore. This is called a tension pneumothorax and MUST be treated immediately.

This illustration depicts the insertion of a chest tub, a flexible tube that is placed into the space that fills up with stuff to allow the blood or air to drain back out. Just sticking a tube into the wound isn’t going to help much though. Chest tubes use basic principles of pressure differentials to “seal” the tube so air and blood can leak OUT but air and germs can’t get back IN.

All this scientific stuff is neat, but how does it FEEL?

Speaking from experience, broken ribs HURT. And by hurt, I mean it sort of feels like someone is sticking a high-heeled shoe straight into your lungs and giving it a little twist. That said, it is certainly possible to battle through the pain, especially when the injury is fresh and all those endorphins (brain chemicals that tell your brain to ignore pain) and adrenaline are sloshing around inside you. I personally took three good swings with a baseball bat at the jackass who broke two of my ribs before the pain hit. (He was much bigger and stronger than me. The bat evened things out nicely) After the pain hit, I did a lot of walking humped over, holding my side, and generally being miserable for a couple of months. Life went on.

How long does it take to recover?

Bruised ribs and torn cartilage usually take 3-4 weeks to recover. Fractured bones, 6-8 weeks. However, this rate is GREATLY impacted by numerous factors and the healing can take MUCH longer. This is great news for our intrepid writer, as you can really play with the time factor here. My personal rib injury still gives me significant trouble off and on 15 years later.

Factors that increase time to heal:

• Old age
• Osteoporosis or generally weak bones
• Reinjuring the area (like the folks who continue to play football with cracked or broken ribs)
• Not resting enough (like that character who’s going to be dodging bullets or swinging swords)
• Other injuries – the body has limited resources and not all things are equal
• Nutrition – bones and cartilage require certain components to heal, like calcium and especially protein. Healing will still happen for folks with very poor diets, because the body will rob from other areas eventually, but proper nutrition will help speed healing and prevent infection
• Infection – infected tissue doesn’t heal. Basically, the body has other things on its mind if it’s trying to put out fires
• Severity of the injury – a complete break along the full thickness of the bone is going to take longer to heal than a partial fracture. Likewise, multiple rib fractures or multiple torn cartilages will not provide adequate support for each other to heal and may slow the process down a bit

Rib injuries can be a nice way to give your characters unpleasant lives for a while and make things just that much harder on them, but by themselves they aren’t going to keep a determined hero or villain out of action most of the time. They’ll hurt enough to discourage athletics, but those endorphins and adrenaline can work magic even here in the real world.