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Article

Rib Fractures: A Review of Presenting Factors, Associated Injuries and Outcomes at a Level 1 Trauma Facility

by
Estelle Laney
*,
Shumani Makhadi
,
Ekene Emmanuel Nweke
,
Nnenna Elebo
and
Maeyane Stephens Moeng
Department of Surgery, University of the Witwatersrand, Johannesburg 2193, South Africa
*
Author to whom correspondence should be addressed.
Trauma Care 2025, 5(4), 25; https://doi.org/10.3390/traumacare5040025
Submission received: 5 August 2025 / Revised: 30 August 2025 / Accepted: 1 September 2025 / Published: 30 October 2025
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Abstract

Background: Fractured ribs remain a significant cause of morbidity and are associated with severe injuries requiring several healthcare resources and may be associated with prolonged hospital stays that may require an ICU facility. In our facility, we have a high burden of patients sustaining rib fractures, and we aim to compare management options, outcomes, and factors associated with mortality from a single center. Methods: A retrospective review was performed on patients who presented with rib fractures at a Level 1 Trauma facility in Johannesburg, undergoing medical or surgical management. The study included data from 1 July 2011 until 31 December 2020. All patients were identified using the Medibank database. STATA Version 18 software was used for all data analysis. A p-value of <0.05 was considered statistically significant. Injuries were subdivided according to the Abbreviated Injury Severity score as follows, Mild = AIS Grade I–II, Moderate = AIS Grade III, Severe AIS Grade IV–V. Results: There was a total of 940 patients. The median age was 45 (IQR: 34–55) years, with 22% female patients in a cohort of 940. The mechanism of injury was blunt in 96%. Most patients (93%) fractured 3/> ribs. Only 4.6% sustained a flail chest. The median SBP was 126 mmHg (IQR:109–144), and the pulse rate was 91 (IQR: 79–108) beats per minute. The mean Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 17 (IQR: 10–29) and 22 (IQR: 14–34), respectively. The most common associated injuries were chest trauma in 42%, combined abdominal and pelvic trauma in 35%, and severe extremity trauma in 37%. The mortality rate was 17% (159/940). Most patients required medical and supportive management, with only 8% undergoing rib plating (76/940). The mean length of stay was 14 days (IQR: 6–25). Statistically significant factors associated with mortality were rib fractures 3≥, flail chest, higher ISS, severe head, neck, chest, abdomen and pelvis injuries (p-value 0.001) and severe extremity injury (p-value 0.006). Conclusions: Rib fractures remain a common pathology in the trauma population, and these patients can have significant associated injuries. With an appropriate multidisciplinary approach, our study found an 83% survival rate, and only 8% of patients requiring surgical intervention. Poor outcomes in patients are directly linked to the number of ribs involved, the injury severity score, associated injuries, and advanced age.

1. Introduction

Fractured ribs are a major cause of morbidity and are indicative of significant trauma to the thoracic cavity [1,2,3,4]. Rib fractures have a high association with other potential life-threatening concomitant injuries requiring ICU care and close monitoring in the majority of the cases involved [5,6,7,8,9]. A multidisciplinary approach is necessary to optimize outcomes in these injured patients.
General supportive care requires ventilatory support if oxygenation is compromised or indicated by associated major organ dysfunction or head injury [10]. This is accompanied by high-quality physiotherapy and monitoring for possible infection complications. Pain control remains pivotal in optimizing outcomes in rib fracture patients, and it can be administered by systemic means or regional pain control options. Epidural blocks are an effective regional pain control option; however, they are not always available in Lower-Middle-Income Country (LMIC) settings, defined by the World Bank as a country having a Gross National Income of USD 1136–4495 [11,12,13,14].
Recent interest in stabilization of the ribcage by utilizing rib fixation has gained more popularity. The impact on ICU length-of-stay and ventilation requirements has been reported with conflicting results [15]. The procedure has become more refined and can be achieved with minimal surgical exposure while retaining the rib periosteum. There is also no need to open the chest cavity unless associated with retained hemothorax, thus, allowing for a complete isolated chest wall procedure. Rib fixation is a surgical procedure and also has known complications. The quality-of-life outcomes are more favorable than the immediate hospital quality-of-life benefits [15,16,17,18,19].
In South Africa, we have many trauma cases and associated rib fractures [20]. The growing disparity in the wealth of South Africans also highlights the prevalence of unskilled laborers who perform heavy manual labor for survival [20]. This offers a unique opportunity to evaluate the ability of these patients to return to a productive work environment if they indeed benefit from the stabilization of the chest wall by rib fixation.
The Level 1 Trauma Center involved has in-house protocols to maintain the standard of care and follow international guidelines on the management of trauma [21]. The unit also has multidisciplinary teams to ensure quality management and control of cases. The multimodality approach to pain management includes systemic and regional pain control ventilatory support if indicated, comprehensive care including monitoring and allied support, and surgical rib fixation when indicated [22]. This unit receives several blunt trauma chest injuries, with some of the injuries being work-related injuries. The study aimed to evaluate management options and outcomes of patients presenting with fractured ribs at a single Level One Trauma unit in Johannesburg. The study will add to the literature of the management of rib fractures in LMICS.

2. Materials and Methods

A retrospective review of trauma patients who sustained rib fractures was performed at a Level 1 Trauma Center in Johannesburg South Africa. The study included data from 1 July 2011 until 31 December 2020. All patients were identified using the Medibank database, entered into a Microsoft Excel spreadsheet, and appropriately anonymized. Ethical clearance was approved by the University of Witwatersrand Human Research Ethics Committee with Clearance Number (M180502).
All patients 18 years and older who sustained rib fractures were included in the study. Exclusion criteria were patients with incomplete records. Data collected included demographics (age and sex), mechanism of injury, physiological factors (Revised Trauma Score, Injury Severity Score, New injury Severity score, Probability of Survival), pattern and number of rib fractures, associated injuries noted, medical treatment offered, surgical treatment offered, ICU length of stay, Hospital length of stay and In-hospital mortality. Associated injuries were recorded. For this study, more than three rib fractures in two or more places were referred to as a flail [22].
Indications for rib fixation in the unit include flail chest, significant rib displacement with multiple fractured ribs, specifically if involving anterolateral ribs 4–10, difficulty in weaning from the ventilator, and severe pain not responding to multimodal analgesia. All patients received physiotherapy and incentive spirometry. Our analgesic approach includes opioids, NSAIDS, and then adjuvants such as Gabapentin or Amitriptyline. If there was no response, we proceeded to a pleural block, and if needed an epidural.
Descriptive statistics were used to analyze the data. Statistical difference between comparable groups was calculated using Pearson’s Chi-square (X2) for categorical variables and the Mann–Whitney test for continuous variables. Means with standard deviations (SD) were used for normally distributed data and median were represented with the interquartile range (IQR) for non-parametric values. Frequencies (%) were used for categorical variables. Multivariate analysis, univariate analysis and stepwise logistic regression were used to assess for independent predictors of outcomes. STATA Version 18 software (Stata Corp, College Station, TX, USA) was used for all data analysis. A p-value of 0.05 was considered statistically significant [23].

3. Results

During the study period, a total of 940 patients were identified. In total we had 7750 patients in this time period, with a 12.12% (940/7750) incidence of rib fractures. The mean age was 45 years, and 22% were female patients. The mechanism of injury was blunt in 96% (n = 899) patients and penetrating in 4% (n = 41) patients. Most patients 67% (n = 630) fractured three or more ribs, with only 44 patients having sustained a flail chest. A detailed description of the demographics is outlined in Table 1. On presentation, the mean Systolic Blood Pressure was 126 mmHg (IQR: 109–144), and the pulse rate was 91(IQR: 79–108) beats per minute. The mean Injury Severity Score and New Injury Severity Score were 17 (IQR: 10–29), and 22 (IQR:14–34), respectively.
Associated injuries are outlined in Table 2, with most common associated injuries noted within the chest in 42% of the cases followed by extremity injuries in 37% and associated abdominal and pelvic trauma in 35%.
There were 781 patients discharged (83%) and a mortality rate of 17% (159/940). The 30-day mortality rate was 93% (148/159). Only 8% of the patients assessed fit the criteria for rib fixation (76/940). The mean length of stay was 14 days (Table 1). For the patients that died three or more ribs were fractured, or if a flail chest was present, it was associated with a worse outcome, with a p value of <0.001. A higher ISS and NISS were noted in the mortality group of 35 and 45, respectively (p value < 0.001) (Table 3).
Mortality in patients < 65 years was 14% (110/771) compared with 29% (49/169) in those > 65 years. Patients of <65 years had significantly lower odds of death than those > 65 years (odds ratio 0.41; 95% CI 0.28–0.60; p < 0.0001), as seen in Figure 1.
In the surgery group, patients were more prone to surgery if they had 3 ≥ affected ribs (p value < 0.001). Interestingly, the median length of stay was longer in the operated group, 13 vs. 29 days (p-value < 0.001) but this might be attributable to associated injuries. There was no difference in mortality rate between the operated and non-surgical groups.
Kaplan–Meier analysis was performed to assess how surgical vs. medical management affected the outcomes and disposition of the patients. As seen in Figure 2, whether or not surgical fixation was performed did not affect the mortality rate.

4. Discussion

Rib fractures are a common injury, sustained predominantly post blunt chest trauma [1]. It has been described in 10–20% of all trauma patients and 10% of blunt cases, which is in keeping with our incidence of 12% [16,17]. The clinical importance of rib fractures relates to the impact they have on morbidity and mortality, leading to a significant burden on the healthcare system [17]. This retrospective study assesses multiple characteristics associated with rib fractures and their outcomes.
The impact of rib fractures can range from debilitating pain upon discharge to significant morbidity during hospital admission. These include increased lower respiratory tract infections, increased days of ventilation and ICU stay, and an increased hospital stay [17,25].
Certain risk factors have been identified that can correlate to worse outcomes, namely elderly patients, the number of fractures, and significant associated injuries [25,26]. A specific component with poor outcomes is a clinical flail chest, defined as a contiguous segment of three or more ribs with two or more fractures. A Flail chest has significantly higher mortality and respiratory failure [25,26].
A flail chest can be diagnosed on radiological investigations or be a clinical diagnosis when paradoxical chest movements are identified during respiration [26]. These patients experience excessive pain due to the magnitude of fractures and subsequently do not mobilize or cough adequately. This pain leads to splinting and atelectasis, and the patient is prone to pneumonia. These injuries are complicated due to the excessive pain the patients experience that leads to splinting. This will inevitably lead to prolonged ventilation and ICU stay [23,27].
In our study, patients with more than 3 rib fractures, flail segments, and significant associated injuries had worse outcomes. The minority of our patients had surgical fixation, but this correlates to the literature. Despite the success and popularity of surgical fixation, most patients did not require any surgical intervention [27].
The management of patients with rib fractures revolves around pain management, positive pressure ventilation when indicated, and surgical fixation in a specific group of patients [23,25,26,27]. Pain management consists of systemic measures, such as opioids, paracetamol and NSAIDs, as well as locoregional options, including epidurals, intercostal blocks, and paravertebral and pleural blocks. Currently, the recommended approach by EAST guidelines is multimodal, which uses all of the above measures [28].
A measure of appropriate pain control and identifying the patient at risk of poor outcome have been described in different scoring systems. The SCARF and BATTLE score include age, number of rib fractures, high pain scores, and other co-morbidities. The thoracic trauma severity score can also be used, and has been shown to be superior in predicting outcomes for the respiratory system. This score includes PF ratio, number of fractures, age and whether contusions or pleural involvement is present [29].
Due to the impact that multiple rib fractures have on ventilation, gas exchange, and chest wall motion, it is essential to have physiotherapy with incentive spirometry and a multidisciplinary approach to these patients to prevent pulmonary complications [30]. Not all patients with multiple rib fractures will require ventilation; however, if sustained hypoxia and high oxygen requirements, Non-invasive ventilation can be used prior to committing to intubation according to EAST guidelines [28,30].
This study has also shown how rib fractures are associated with several severe injuries, and it should be seen as a marker of severity. It must give a suspicion to the clinician regarding the impact and energy transfer of the injury and emphasize the high degree of suspicion for associated injury, and for a comprehensive evaluation. In our study we found associated chest injuries and extremity trauma to be the most common. The amount of abdominal trauma (35.1%) closely coincides with a retrospective review performed in 2020 in Japan, reporting abdominal trauma in 34.9% of patients, predominantly solid organ injury [31]. The mortality rate associated with rib fractures was found to be 17% in our study. This coincides with the literature, as shown in an epidemiological study performed in the Netherlands [32] reporting 10–22% mortality rate in patients with rib fractures.
The importance of age in mortality rate was emphasized in our study, with a p-value < 0.0001 when comparing patient mortality in age groups of <65 years and >65 years. This demonstrates that advanced age was associated with approximately a two-fold higher risk of mortality in this cohort.
In a country with limited resources and most patients performing hard labor, the impact of rib fractures is a concern with reports of chronic pain present in 22% and some form of disability in 53% of cases 6 months after injury, not only with flail chests, but even in isolated rib fracture patients [24,26]. Given the impact rib fractures have on the healthcare system, with regard to morbidity and mortality, the aim should be to risk stratify patients, identify complications early, and develop management approaches to decrease the negative effects on the patient’s physiology [25,33].
The limitations of our study include that this is a retrospective review with its shortcomings. A single-center study may have unplanned selection bias. No long-term follow-up was available for the study, including the return to physical duty. The study only assesses patients admitted to our Level 1 facility who tend to be seriously injured. Thus, patients discharged home with minimal or undisplaced fractures might experience complications of which we are unaware.

5. Conclusions

Rib fractures remain a common pathology in the trauma population, and these patients can have significant associated injuries. With an appropriate multidisciplinary approach, our study found an 83% survival rate, and only 8% of patients requiring surgical intervention. Poor outcomes in patients are directly linked to the number of ribs involved, the injury severity score, associated injuries, and advanced age.

Author Contributions

Conceptualization, M.S.M. and E.L.; methodology, E.L. and M.S.M.; software, N.E.; validation, N.E.; formal analysis, N.E.; investigation, E.L.; data curation, E.L., N.E. and M.S.M.; writing—original draft preparation, E.L.; writing—review and editing, M.S.M., S.M. and E.E.N.; visualization, M.S.M.; supervision, M.S.M. and S.M. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

University of Witwatersrand Human Research Ethics Committee with Clearance Number (M180502) on 25 February 2018.

Informed Consent Statement

Patient consent was waived as data was collected in an anonymous fashion using allocated case numbers, protecting patient identity throughout the study.

Data Availability Statement

Data is unavailable due to privacy or ethical restrictions.

Conflicts of Interest

The authors declare no conflicts of interest.

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Traumacare 05 00025 g001
Figure 1. Mortality by age group. Patients > 65 years had significantly higher mortality compared with those < 65 years (p < 0.0001).
Figure 1. Mortality by age group. Patients > 65 years had significantly higher mortality compared with those < 65 years (p < 0.0001).
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Figure 2. Kaplan–Meier Survival in-hospital estimates. Strata 0 (Non-Operated) vs. Starta 1 (Operated).
Figure 2. Kaplan–Meier Survival in-hospital estimates. Strata 0 (Non-Operated) vs. Starta 1 (Operated).
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Table 1. Demography and Clinical Features of Trauma Patients.
Table 1. Demography and Clinical Features of Trauma Patients.
FeaturesSubtypesn (Percentage)
Incidence of Rib fracturesTotal 7750 940 (12%)
Age 45 (34–55)
GenderMale737 (78%)
Female203 (22%)
EthnicityWhite423 (45%)
African420 (45%)
Indian49 (5%)
Others25 (3%)
Unknown23 (2%)
Mechanism of injuryBlunt899 (96%)
Penetrating41 (4%)
Rib Fractures<2169 (18%)
2–3146 (16%)
>3625 (66%)
[Clinical Flail Segment]44 (5%)
Systolic Blood Pressure median [IQR] 126 (109–144)
Pulse median [IQR] 91 (79–108)
ISS median [IQR] 17 (10–29)
NISS median [IQR] 22 (14–34)
Rib fixation 76 (8%)
LOS (in days) median [IQR] 14 (6–25)
Discharged 781 (83%)
Died 159 (17%)
30-day mortality 148 (93%)
ISS = Injury Severity Score, NISS = New Injury Severity Score, LOS = Hospital Length of Stay, IQR = Interquartile Range.
Table 2. Percentage of Associated injuries of Trauma Patients.
Table 2. Percentage of Associated injuries of Trauma Patients.
Associated InjuriesSubtypesPercentageTotal
ChestMild—Other associated fractures (sternum, scapula)106 (27%)396 (42.1%)
Moderate—Associated Cardiac, lung contusions221 (56%)
Severe—Major Contusions and fractures, or combined other injuries (aortic, diaphragm rupture)69 (17%)
Head Mild—Facial fractures, concussion95 (31%)306 (32.55%)
Moderate—Above plus minus TBI isolated bleed/BOS fracture108 (35%)
Severe—Above plus TBI multiple bleeds, cerebral edema, DAI103 (34%)
SpineMild—Isolated C, L or T-spine isolated112 (42%)269 (28.6%)
Moderate—Multiple C, L or T spine87 (32%)
Severe—C, L and T spine, or associated injury70 (26%)
AbdomenMild—1 organ injured105 (32%)330 (35.1%)
Moderate—2/> organs injured, Isolated pelvic fracture139 (42%)
Severe—3/> organs injured, or abdominal injury with associated pelvic fracture86 (26%)
ExtremitiesMild—1 fracture199 (57%)351 (37.3%)
Moderate—2–3 fractures93 (26%)
Severe—>3 fractures59 (17%)
TBI = Traumatic Brain Injury, BOS = Base of Skull, DAI = Diffuse Axonal Injury, C = Cervical spine, T = Thoracic spine, L = Lumbar spine Mild = AIS Grade I–II, Moderate = AIS III, Severe AIS (IV–V) [24].
Table 3. Survival variables: comparing in-hospital Alive and Dead patients in the cohort.
Table 3. Survival variables: comparing in-hospital Alive and Dead patients in the cohort.
VariablesSubtypesAlive n = (%) or Median (Q1–Q3)Dead n = (%) or Median (Q1–Q3)p-Value
Rib fractures1150 (89%)19 (11%)<0.001
2–3127 (87%)19 (13%)
>3476 (82%)105 (18%)
Flail segment28 (64%)16 (36%)
Age<65 years661 (86%)110 (14%)<0.0001
>65 years120 (71%)49 (29%)
Head, neck, C-spineMild86 (91%)9 (9%)<0.001
Moderate80 (74%)28 (26%)
Severe44 (43%)59 (57%)
ChestMild92 (87%)14 (13%)0.027
Moderate163 (74%)58 (26%)
Severe52 (75%)17 (25%)
AbdomenMild83 (79%)22 (21%)0.001
Moderate106 (76%)33 (24%)
Severe48 (56%)38 (44%)
ExtremityMild164 (82%)35 (18%)0.006
Moderate72 (77%)21 (23%)
Severe37 (63%)22 (37%)
Systolic BP (mmHg) 129 (115–145)103 (68–132)<0.001
Pulse 90 (78–104)107 (83–124)<0.001
ISS 18 (10)35 (13)<0.001
NiSS 23 (13)45 (17)<0.001
Length of Stay(days) 16 (9–27)1 (0–9)<0.001
MOI = Mechanism of injury, BP = Blood Pressure, ISS = Injury Severity Score, NiSS = New Injury Severity Score, Mild = AIS Grade I–II, Moderate = AIS III, Severe AIS (IV–V).
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Laney, E.; Makhadi, S.; Nweke, E.E.; Elebo, N.; Moeng, M.S. Rib Fractures: A Review of Presenting Factors, Associated Injuries and Outcomes at a Level 1 Trauma Facility. Trauma Care 2025, 5, 25. https://doi.org/10.3390/traumacare5040025

AMA Style

Laney E, Makhadi S, Nweke EE, Elebo N, Moeng MS. Rib Fractures: A Review of Presenting Factors, Associated Injuries and Outcomes at a Level 1 Trauma Facility. Trauma Care. 2025; 5(4):25. https://doi.org/10.3390/traumacare5040025

Chicago/Turabian Style

Laney, Estelle, Shumani Makhadi, Ekene Emmanuel Nweke, Nnenna Elebo, and Maeyane Stephens Moeng. 2025. "Rib Fractures: A Review of Presenting Factors, Associated Injuries and Outcomes at a Level 1 Trauma Facility" Trauma Care 5, no. 4: 25. https://doi.org/10.3390/traumacare5040025

APA Style

Laney, E., Makhadi, S., Nweke, E. E., Elebo, N., & Moeng, M. S. (2025). Rib Fractures: A Review of Presenting Factors, Associated Injuries and Outcomes at a Level 1 Trauma Facility. Trauma Care, 5(4), 25. https://doi.org/10.3390/traumacare5040025

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