June 27, 2026
Rib fractures are among the most common chest wall injuries and can trigger a cascade of physiologic challenges. Pain‑limited ventilation often leads to shallow breathing, predisposing patients to atelectasis and pneumonia — risks that are especially concerning in older adults, frail patients and those who are immunocompromised. The blunt force trauma that may fracture ribs also may lacerate or contuse underlying organs, including the lungs, liver or spleen, or damage intercostal vessels, resulting in hemothorax or pneumothorax.
A subset of patients develops flail chest, in which a segment of the chest wall becomes mechanically unstable and may move paradoxically during respiration, according to a 2022 article in Scandinavian Journal of Trauma. This condition significantly impairs ventilation, increases the work of breathing, and is strongly associated with respiratory failure and prolonged ICU stays.
Sternal fractures share many of the same risks. Beyond pain‑limited ventilation, they may be associated with cardiac contusion, blunt aortic injury and secondary rib fractures. Pulmonary contusion, atelectasis and pneumonia remain common complications, particularly when the injury is associated with high‑energy mechanisms.
In adults, chest wall injuries most often result from motor vehicle collisions or other high‑force impacts, such as direct blows from sports. Falls are another common mechanism for chest wall trauma.
Chest wall injury in children
Chest wall trauma is less common in children due to key anatomic differences. Pediatric ribs are more flexible and absorb force without fracturing, which can mask the severity of underlying injury.
"Kids bend and don't break easily — they're more pliable," notes Brian D. Kim, M.D., an acute care and general surgeon at Mayo Clinic in Minnesota.
When chest wall injury does occur, children are more likely to sustain pulmonary contusions than rib fractures or pneumothorax, explains Denise B. Klinkner, M.D., M.Ed., a pediatric trauma surgeon and medical director of the Level 1 Pediatric Trauma Center at Mayo Clinic. Rib fractures become more common around ages 10 to 11 as calcification increases. The mediastinum remains mobile until approximately ages 12 to 14, which influences injury patterns and risk of aortic injury.
Dr. Klinkner emphasizes that a standard pediatric chest X‑ray generally eliminates the need for CT imaging, reducing unnecessary radiation exposure. Common mechanisms include kicks from animals, impacts from ATV handlebars and steering wheel injuries in adolescents. As the mediastinum stiffens in adolescence, the risk of aortic injury increases.
In cases of suspected child abuse, healing rib fractures with callus formation are a key diagnostic clue, says Dr. Klinkner. Families often present after repeated episodes rather than at the time of initial injury.
Clinicians also should be aware that some injuries evolve over time. Pulmonary contusions may not manifest significant respiratory symptoms until 24 hours postinjury, as edema develops. These patients often require increased respiratory support the day after arrival.
Current ACS recommendations for chest wall injury management
The American College of Surgeons (ACS) outlines several best practices for managing chest wall trauma:
Multimodal pain control. Effective analgesia is essential to restore adequate ventilation. The ACS recommends minimizing reliance on opioids and incorporating epidural analgesia, paravertebral blocks or serratus anterior plane blocks when appropriate.
Surgical stabilization of rib fractures (SSRF). For patients with flail chest and acute respiratory failure, SSRF using titanium plates has been demonstrated to improve outcomes. The ACS also supports SSRF in select patients with multiple displaced rib fractures without flail chest patterns.
Optimal timing of SSRF. Early intervention — ideally within three days of injury — reduces ventilator days, ICU length of stay, total hospitalization time and pneumonia risk.
Postoperative and pulmonary care. Early ambulation and aggressive pulmonary hygiene are critical to preventing respiratory complications. The ACS also outlines best practices for monitoring lung function and managing the pleural space.
Special considerations for older adults and polytrauma patients. Patients with pulmonary contusions or traumatic brain injuries require tailored management strategies to balance respiratory support, neurologic protection and pain control.
Key steps for smaller trauma centers
For facilities without advanced surgical capability, the priority is physiologic stabilization of the patient. The next priority is providing effective pain control and identifying patients who require transfer to a higher level trauma center for definitive management, such as SSRF or critical care.
When patients with fewer, nondisplaced rib fractures stay closer to home, patient outcomes are best with a focus on pain control and aggressive pulmonary toilet.
For more information
Lundin A, et al. Thoracic injuries in trauma patients: Epidemiology and its influence on mortality. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2022;30:69.
Best Practices Guidelines: Management of Chest Wall Injuries. American College of Surgeons.