Rib Fractures Dr. D. N. Bid

Background

• Simple rib #s are the most common injury sustained following blunt chest trauma.

• Approximately 10% of all patients admitted after blunt chest trauma have one or more rib #s.

• These #s are rarely life-threatening in themselves but can be an external marker of more severe visceral injury inside the abdomen and the chest.

• The most common mechanism of injury for rib #s in elderly persons is a fall from height or from standing.

• In adults, MVA is the most common mechanism.

• Youths sustain rib #s most often secondary to recreational and athletic activities, as well as by non-accidental trauma.

• Rib #s may also be pathologic. Cancers that metastasize to bone (eg, prostate, breast, renal) frequently become apparent in a rib.

• Ribs are relatively thin compared with major long bones and are more likely to # when invaded by a metastatic lesion.

• The chest wall protects underlying sensitive structures by surrounding internal organs with hard osseous structures including the ribs, clavicles, sternum, and scapulae.

• An intact chest wall is necessary for normal respiration.

• Rib #s may compromise ventilation by a variety of mechanisms. Pain from rib #s can cause respiratory splinting, resulting in atelectasis and pneumonia.

• Multiple contiguous rib #s (i.e., flail chest) interfere with normal costovertebral and diaphragmatic muscle excursion, potentially causing ventilatory insufficiency.

• Fragments of #ed ribs can also act as penetrating objects leading to the formation of a hemothorax or a pneumothorax.

• Ribs commonly # at the point of impact or at the posterior angle (structurally their weakest area). Ribs four through nine (4-9) are the most commonly injured.

• The thinnest and weakest portion of the first rib is at the groove for the subclavian artery.

• The mechanism of first-rib injury in MVAs seems to be a violent contraction of the scalene muscles brought on by the sudden forward movement of the head and neck.

• A single blow may cause rib #s in multiple places.

• Traumatic #s most often occur at the site of impact or the posterolateral bend, where the rib is weakest.

• Due to the greater pliability of children's ribs, greater force is required to produce a #.

Mortality/Morbidity

• Rib #s are not usually dangerous in and of themselves.

• Patients may develop pneumonia from splinting.

• Morbidity correlates with the degree of injury to underlying structures.

Age

• Because children have more elastic ribs, they are less likely than adults to sustain #s following blunt chest trauma.

• Elderly individuals are more likely to have associated injuries and complications.

Clinical Presentation

• Description of the prehospital scene by paramedics can provide important clues to the possibility of rib #s.

• After MVA, deformation of the steering wheel and activation of seat belts and airbags have been associated with rib injuries.

• Patients with rib # frequently complain of pain on inspiration and dyspnea.

• Rib #s have been reported after coughing spells without other significant trauma.

• Athletes with high force, recurrent movements of the arms (e.g., discus throwers) have had stress #s of the upper and middle ribs.

• Tenderness on palpation, crepitus, and chest wall deformity are common findings of rib #.

• Paradoxical chest wall excursion with inspiration is seen with flail chest.

• A flail chest occurs when a large segment of ribs is not attached to the spine.

• These ribs are broken in at least 2 places on each rib.

• The paradoxical movement occurs because the middle section of the rib between the 2 # sites moves in response to intrathoracic pressure changes not intercostal muscle contractions.

• Specific signs of ventilatory insufficiency include cyanosis, tachypnea, retractions, and use of accessory muscles for ventilation.

• Less specific signs include anxiety and agitation.

• Bruising near # site is uncommon in pediatric rib #s.

• If # of the lower ribs is suspected, assess the patient for abdominal tenderness and costal margin tenderness, which could raise suspicion for injury to intra-abdominal organs.

Causes

• Blunt trauma including motor vehicle crashes, assault, falls, especially down staircases.

• Coughing spells• Non-accidental trauma in

pediatric cases• Repetitive minor trauma• Stress #s to the first rib in

throwing athletes

Chest radiographs

• AP and lateral chest films are used routinely to assist in the diagnosis of rib #s.

• Chest radiographs are much more useful in the diagnosis of underlying injuries, including hemothorax, pneumothorax, lung contusion, atelectasis, pneumonia, and vascular injuries.

• Findings of sternal # or scapular # should increase suspicion for rib #s.

Prehospital Care

• Prehospital care should focus on airway maintenance and supplemental oxygen.

Emergency care

• Goal of initial ED care is stabilization of the trauma patient and multisystem trauma evaluation.

• Respiratory care, including use of incentive spirometry to prevent atelectasis and its complications, is often important.

• Holding a pillow or similar soft brace against the # site reduces discomfort while using the spirometer or when coughing.

• Pain control is fundamental to the management of rib #s to decrease chest wall splinting and alveolar collapse in order to clear pulmonary secretions.

• Isolated rib #s, without associated injuries, may be managed on an outpatient basis with oral analgesics, starting with NSAIDs if not contraindicated and progressing to narcotics if not sufficient.

• While rib belts or binders do control pain, they have been linked to hypoventilation, atelectasis, and pneumonia.

• As a result, their use is no longer recommended.

• For patients with a significant mechanism of trauma, a CT of the chest and abdomen can be useful in scanning for significant related injury.

• It is recommended that hospital admission for any patient with 3 or more rib #s, and ICU care for elderly patients with 6 or more rib #s.

Further Outpatient Care

• Patients with minor rib injuries able to cough and clear secretions may be discharged with adequate analgesic medications.

• Adequate analgesics are critical to successful outpatient management of rib #s.

• Most patients who will develop complications will do so within 2 weeks, so a follow-up plan within 2 weeks should be made.

• Consider an incentive spirometer, especially with multiple #s, as it may help avoid complications and remind the patient to avoid splinting and to take deep breaths.

Further Inpatient Care• Patients with isolated rib #s who are unable to cough and

clear secretions adequately should be considered for admission for 24-hour observation.

• Consider admission for patients with underlying lung disease or decreased pulmonary reserve.

• A lower threshold for admission of older persons with isolated rib #s is warranted because of their higher incidence of hypoventilation, hypercapnia, atelectasis, and pneumonia.

Prognosis

• Isolated rib #s in younger patients have a good prognosis.

• Older patients have a higher incidence of significant pulmonary complications.

Patient Education• Return to work or sport depends on the activity involved and

the level of pain.

• Heavy labor and intensive training for athletes with stress #s are not recommended for the first 3 weeks.

• When pain is not present at rest, the patient can begin to increase his or her activity level but this should be gradually done.

• Most rib #s heal within 6 weeks.

• Virtually all nonpathologic rib #s heal well with conservative management.

• Some patients are able to return to work within a few days, depending on their occupation.

Thank you..

Fracture of the sternum• Fracture of the sternum can be caused either by direct

trauma, which requires extreme force and is usually associated with other injuries, or by violent flexion of the thoracic spine accompanied by a wedge fracture of the thoracic spine.

• Fractures of the sternum are not serious in themselves and usually unite soundly, but their presence should alert the doctor to the possibility of a more serious injury. A flail segment including the mediastinum may be difficult to control, even by positive pressure respiration (see Fig. 11.3).

• TreatmentIf the fractured sternum is not properly aligned it may need reduction and wiring.