Anupam Kharbanda, in, 2007 Clinical PresentationRib fractures are seen in 30% to 50% of children with chest injuries. 38 Physical examination findings consistent with rib fracture are localized pain, palpable deformity, and crepitus.
Roland camm 1 pnc 960 drivers for mac. Occasionally it is necessary to cough, but I soon found out that that is a big mistake when you have some broken ribs. And sneezing is a truly memorable experience! This time the cracked rib wasn’t nearly so serious, just one middle rib in the middle, so I didn’t even bother to bother a doctor with my travails, and have chosen to simply be.
The location of a rib fracture provides information about other injuries the child may have sustained. The upper ribs are well protected by other anatomic structures such as the scapula, humerus, and clavicle; therefore, the middle ribs are most commonly injured. Fractures of the upper ribs should raise the suspicion of intrathoracic or cervical injury. 39 Fractures of the lower ribs are associated with abdominal injuries.
Ian Civil, in, 2007 Rib FracturesRib fractures are the most common significant injury to the thorax. They occur after a wide range of injuries and become increasingly common as age increases and the flexibility of the rib cage decreases. Diagnosis is largely clinical because one or two fractures are not always apparent on a chest radiograph.
Multiple rib fractures usually can be seen ( Fig. Rib fractures may be associated with underlying lung injury such as pneumothorax, hemothorax, or pulmonary contusion.Treatment is supportive: it includes oxygen for hypoxemia as well as physical therapy and adequate analgesia. Rib fractures are extremely painful and they may have a major impact on a patient's ability to breathe and cough. For patients with severe pain or respiratory compromise, epidural analgesia or intermittent intercostal nerve blocks may be used. Alternatively, an opioid administered via a patient-controlled analgesia system in combination with regular acetaminophen and a nonsteroidal antiinflammatory drug may be used. Broder MD, FACEP, in, 2011 Rib FracturesRib fractures are the most common thoracic injury and are a frequent finding on chest x-ray after trauma ( Figures 6-121 through 6-124). 26 Rib films are not typically indicated to assess for rib fracture, as it is the underlying parenchymal injury or the clinical status of the patient that most often drives management.
26 The x-ray should be inspected for associated pneumothoraces, pleural effusions (hemothorax), and pulmonary contusions. CT is also not routinely indicated to pursue rib fractures, unless other important thoracic injuries are suspected.Ribs should be traced from their articulation with the facets of the thoracic spine, through their course, to the sternum.
Displaced fractures are usually readily apparent and should not distract from a separate thorough search for associated pneumothorax, hemothorax, or pulmonary contusion as described earlier. Subtle cortical defects can be harder to recognize. The overlap of ribs can create confusing intersecting lines that may be mistaken for or may disguise fractures. Solitary rib fractures may occur, but as with other ring structures in the body, ribs often fracture in multiple locations or become displaced at articulations with other structures, so detection of a rib fracture should prompt a search for additional fractures or dislocations. If two or more adjacent ribs are fractured in two or more places, a “flail segment” is present, which may significantly interfere with respiratory mechanics. Patients with flail segments are at increased risk for respiratory failure requiring mechanical ventilation with either continuous positive airway pressure or endotracheal intubation. 27 Fractures of the first and second ribs historically have been associated with high-energy mechanisms of trauma and with aortic trauma.
However, several studies suggest no increased risk for aortic injury with upper rib, sternal, scapular, or thoracic spine fractures. 17,18,26,28 Lee et al.
17,18 found that the rate of thoracic aortic injury increased in a statistically significant but not a clinically meaningful degree in patients with rib fractures. 17,18Stawicki et al. 29 noted an increase in mortality associated with rising numbers of rib fractures, particularly in the elderly.
Overall, it is likely that rib fractures are a marker of high-energy trauma and morbidity from other injuries (including extrathoracic injuries), although in this study multiple rib fractures were independent predictors of mortality. 18,30 suggested that three or more rib fractures were an indication for transfer to a trauma center, because of increased mortality, mean injury severity score, mean hospital stay, mean number of intensive care unit days, and rates of liver and spleen injuries. Other studies have shown that pain from rib fractures is a significant cause of disability, with pain persisting well beyond 30 days in some cases.
Freedman, in, 2018 Rib FractureRib fracture was associated with old series of radiation, particularly with the use of orthovoltage radiation due to its giving a higher relative dose to bone than does modern megavoltage radiation. The incidence of rib fracture after breast conserving surgery and radiation in the 1980s and 1990s was reduced to approximately 1% to 2% or less. 51,53,93–95 In the UK START trial, enrolling from 1999 to 2002, the 1% to 2% of reported cases within 10 years included many with history of trauma or metastases. 76 The confirmed cases after imaging and further investigations was 0.3% or less.
Rib pain may not always be associated with abnormalities on imaging. Symptomatic rib fractures related to history of breast radiation may be treated with standard measures of pain medication and incentive spirometry. Recovery is usually within 6 to 8 weeks. Rib fractures ( Figures 5 and 6) are the most common traumatic thoracic injury occurring in almost 40% of thoracic trauma and typically affecting the 4th to 9th ribs ( Sirmali et al., 2003; Liman et al., 2003). Isolated rib fractures are uncommon, occurring in just 13% of all cases of rib fracture ( Sirmali et al., 2003). Traumatic rib fractures are usually associated with other injuries, with three-quarters of patients having concomitant pneumothorax, hemothorax, or hemopneumothorax ( Sirmali et al., 2003).
Motor vehicle accidents are the leading cause of rib fractures, with falls, assaults, and work-place injuries making up the remainder of cases, in decreasing order of frequency ( Sirmali et al., 2003; Liman et al., 2003). Multiple rib fractures are seen in stampede incidents in chaotic, overcrowded, and restricted areas.
Injuries involving the 1st and 2nd ribs are a marker of significant trauma and may be associated with injury to the great vessels ( Liman et al., 2003). Fractures involving the 9th to 12th ribs may be associated with laceration to underlying liver, spleen, or kidneys. Overall mortality secondary to rib fractures is reported to be between 2% and 6% in those patients surviving to hospital presentation, with 3% of all deaths directly attributable to pulmonary injury ( Liman et al., 2003; Sirmali et al., 2003; Brasel et al., 2006). Multiple bilateral anterior rib fractures sustained due to a fall from a height.Flail chest injuries occur where three or more consecutive ribs are fractured in at least two places resulting in a flail segment. Alternatively, injuries may also involve fractures of consecutive ribs with concomitant sternal fracture. Flail chest injuries have been reported to occur in approximately 6% of all traumatic rib fractures, and are associated with significant morbidity and mortality ( Sirmali et al., 2003).
Clinical features include chest wall deformity and paradoxical respiratory chest wall motion. This results in loss of intrathoracic volume with impaired respiration. Flail chest injuries most commonly are the result of blunt chest trauma, usually from motor vehicle accidents, with only occasional case reports describing such injuries secondary to penetrating trauma ( Dehghan et al., 2014; Gamblin and Dalton, 2002). Pneumonia, sepsis, and acute respiratory distress syndrome may complicate this condition ( Dehghan et al., 2014).
Flail chest injuries are reported to carry a mortality of approximately 20%, largely contributed to by associated intracranial, pulmonary, and abdominal injuries ( Sirmali et al., 2003; Liman et al., 2003; Dehghan et al., 2014). This is particularly true of associated pulmonary contusions and significant head injuries, which carry a worse prognosis ( Dehghan et al., 2014).Blunt thoracic wall injuries including multiple rib fractures, fracture of the sternum, and external thoracic wall bruising or abrasion are also seen following cardiopulmonary resuscitation. At autopsy, further signs of attempted resuscitation should be looked for. Perusal of the hospital case files and eliciting a clear history prior to conducting the autopsy is very crucial in proper interpretation of resuscitation injuries ( Fegan-Earl, 2005). Joseph Varon. Bisbal, in, 2008 Chest Wall TraumaRib fractures are the most common chest wall injury.
Rib fractures are an important indicator of underlying injury. Fractures of the first to third ribs are associated with injury to the great vessel and with bronchial injury, whereas lower rib fractures are associated with kidney, liver, and splenic lacerations. Flail chest occurs when three or more ribs are fractured in two places or in multiple fractures associated with sternal fracture. The clinical significance of flail chest varies, depending on the size and location of the flail segment and the extent of the underlying pulmonary contusion. Patients with severe hypoxemia require endotracheal intubation and PPV. 71, 72 Indeed, correction of flail chest occurs with the application of PPV. However, the clinician must observe for late development of pneumothorax, especially tension pneumothorax, in the mechanically ventilated patient.
73Sternal fractures can occur in the trauma patient and are associated with myocardial contusion, cardiac rupture and tamponade, and pulmonary contusion. 74 Early surgical fixation is often necessary; urgent surgery may be indicated when costosternal dislocations compromise the trachea or the neurovascular structures at the thoracic inlet. McKenzie III, in, 2018 Rib Fractures, Pneumothorax, and HemothoraxRib fractures are a fairly common problem, having been reported in 3% to 5% of the general population of neonatal foals and as many as 30% of foals presenting to a neonatal ICU.
Took a big opinion penalty for being a tyrant, and of course her father hates me, and he.is. Crusader kings 2 betrothal.
353 Fractured ribs can cause a number of traumatic insults to the thoracic viscera, including pulmonary contusions and lacerations of the lungs, major arteries, heart, or diaphragm. Pneumothorax, hemothorax, and diaphragmatic herniation may all occur as a result of these traumatic insults, and myocardial injury is typically fatal. Rib fractures can be single, but are often multiple, most often affecting adjacent ribs on one side of the chest. The most common site of injury is at the costochondral junction or immediately dorsal to it. 354 Flail chest, or paradoxic thoracic wall motion, may occur when multiple ribs are fractured, and the affected region will move inward during inspiration and outward during expiration, counter to the movements of the intact portions of the thoracic wall. Rib fractures are commonly found on physical examination by palpation of the fracture itself or by the detection of crepitus at the site of the fracture.
Auscultation may reveal grinding or “clicking” sounds in the area of the fracture as well. Confirmation of the diagnosis is best accomplished ultrasonographically because this modality is much more sensitive than radiography for this purpose. 355 Ultrasonography may also be used to document the presence of air, blood, or abdominal viscera within the thoracic cavity, although radiography may be helpful in this evaluation. Treatment depends on the structures involved and the severity of the complications observed. Most minimally displaced rib fractures, particularly those involving the costochondral junction, can be managed conservatively with stall rest and avoidance of pressure on the affected area when the foal is handled.
Mild to moderate pneumothorax may not require intervention, but if substantial air is presented within the pleural cavity it will cause respiratory distress and should be evacuated. Placement of an indwelling thoracic catheter will facilitate ongoing drainage. If multiple ribs are fractured, and particularly if sharp bony projections are exposed and threatening internal injury, then surgical repair may be indicated.
356 Hemothorax can be life-threatening because of pulmonary compression and/or severe blood loss anemia, and treatment should focus on addressing the primary cause of hemorrhage and patient stabilization and support. Matias Bruzoni MD, Thomas M. Krummel MD, in, 2012 Rib fractures and flail chestRib fractures are unusual in children because of the extreme flexibility of the osseous and cartilaginous framework of the thorax.
The upper ribs are protected by the scapula and related muscles, and the lower ribs are quite resilient. As such, rib fractures are present in only about 3% of children admitted with thoracic injury.
12 Predictably, children with more than one rib fracture are more likely to have sustained multisystem trauma; 13 crush and direct-blow injuries are the usual etiologic factors. Multiple fractures of the middle ribs are almost diagnostic of battered-child syndrome.Multiple rib fractures, resulting in destruction of the integrity of the thoracic skeleton, can cause the paradoxic “flail chest” motion ( Fig. The unsupported area of the chest moves inward with inspiration and outward with expiration; these paradoxical respiratory excursions inexorably lead to dyspnea ( Fig. The explosive expiration of coughing is dissipated and made ineffectual by the paradoxical movement and intercostal pain. In effect, the ideal preparation for acute respiratory distress syndrome—airway obstruction, atelectasis, and pneumonia—has been established.The clinical picture includes local pain that is aggravated by motion. Tenderness is elicited by pressure applied directly over the fracture or elsewhere on the same rib. The fracture site may be edematous and ecchymotic.
The clinical manifestations may range from these minimal findings with simple, restricted fractures to the severest form of ventilatory distress with a flail chest and lung injury. Chest radiographs demonstrate the extent and displacement of the fractures and hint at underlying visceral damage.Treatment of uncomplicated fractures requires pain control to allow unrestricted respiration. Displacement requires no therapy. With severe fractures, alleviation of pain and restoration of cough are important and can be provided by analgesics, physiotherapy, and intermittent positive-pressure breathing.
Thoracentesis and insertion of thoracostomy tubes should be done promptly for pneumothorax and hemothorax ( Figs. 75-3), and shock should be managed by appropriate replacement therapy and oxygen.Paradoxical respiratory excursions with flail chest must be promptly brought under control, sometimes requiring mechanical positive pressure ventilation to help prevent respiratory distress syndrome, which may be the morbid pulmonary complication.
In some cases, a thoracic epidural may be useful to provide appropriate analgesia and achieve effective ventilation. Immediate fixation is rarely indicated. Waldman, in, 2007 Signs and SymptomsRib fractures are aggravated by deep inspiration, coughing, and any movement of the chest wall. Palpation of the affected ribs may elicit pain and reflex spasm of the musculature of the chest wall. Ecchymosis overlying the fractures may be present ( Fig. The clinician should be aware of the possibility of pneumothorax or hemopneumothorax. Damage to the intercostal nerves may produce severe pain and result in reflex splinting of the chest wall, further compromising the patient's pulmonary status.
Failure to treat this pain and splinting aggressively may result in a negative cycle of hypoventilation, atelectasis, and ultimately pneumonia. Jacob MBBS MS (Anatomy), in, 2008Rib fractures can be fracture of a single rib or can be multiple fractures and are caused by direct blow on the rib or by a crush injury.
In a severe crush injury several ribs can fracture in front as well as behind producing a loose segment of chest wall disconnected from the rest. This is known as a ‘stove-in-chest’. The loose segment may show paradoxical movements during respiration i.e.
Moves inwards during inspiration and blows out during expiration. Stove-in-chest is a serious condition needing urgent intubation and positive pressure ventilation using a respirator as well as a chest drain.
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- Category: Category
Anupam Kharbanda, in, 2007 Clinical PresentationRib fractures are seen in 30% to 50% of children with chest injuries. 38 Physical examination findings consistent with rib fracture are localized pain, palpable deformity, and crepitus.
Roland camm 1 pnc 960 drivers for mac. Occasionally it is necessary to cough, but I soon found out that that is a big mistake when you have some broken ribs. And sneezing is a truly memorable experience! This time the cracked rib wasn’t nearly so serious, just one middle rib in the middle, so I didn’t even bother to bother a doctor with my travails, and have chosen to simply be.
The location of a rib fracture provides information about other injuries the child may have sustained. The upper ribs are well protected by other anatomic structures such as the scapula, humerus, and clavicle; therefore, the middle ribs are most commonly injured. Fractures of the upper ribs should raise the suspicion of intrathoracic or cervical injury. 39 Fractures of the lower ribs are associated with abdominal injuries.
Ian Civil, in, 2007 Rib FracturesRib fractures are the most common significant injury to the thorax. They occur after a wide range of injuries and become increasingly common as age increases and the flexibility of the rib cage decreases. Diagnosis is largely clinical because one or two fractures are not always apparent on a chest radiograph.
Multiple rib fractures usually can be seen ( Fig. Rib fractures may be associated with underlying lung injury such as pneumothorax, hemothorax, or pulmonary contusion.Treatment is supportive: it includes oxygen for hypoxemia as well as physical therapy and adequate analgesia. Rib fractures are extremely painful and they may have a major impact on a patient's ability to breathe and cough. For patients with severe pain or respiratory compromise, epidural analgesia or intermittent intercostal nerve blocks may be used. Alternatively, an opioid administered via a patient-controlled analgesia system in combination with regular acetaminophen and a nonsteroidal antiinflammatory drug may be used. Broder MD, FACEP, in, 2011 Rib FracturesRib fractures are the most common thoracic injury and are a frequent finding on chest x-ray after trauma ( Figures 6-121 through 6-124). 26 Rib films are not typically indicated to assess for rib fracture, as it is the underlying parenchymal injury or the clinical status of the patient that most often drives management.
26 The x-ray should be inspected for associated pneumothoraces, pleural effusions (hemothorax), and pulmonary contusions. CT is also not routinely indicated to pursue rib fractures, unless other important thoracic injuries are suspected.Ribs should be traced from their articulation with the facets of the thoracic spine, through their course, to the sternum.
Displaced fractures are usually readily apparent and should not distract from a separate thorough search for associated pneumothorax, hemothorax, or pulmonary contusion as described earlier. Subtle cortical defects can be harder to recognize. The overlap of ribs can create confusing intersecting lines that may be mistaken for or may disguise fractures. Solitary rib fractures may occur, but as with other ring structures in the body, ribs often fracture in multiple locations or become displaced at articulations with other structures, so detection of a rib fracture should prompt a search for additional fractures or dislocations. If two or more adjacent ribs are fractured in two or more places, a “flail segment” is present, which may significantly interfere with respiratory mechanics. Patients with flail segments are at increased risk for respiratory failure requiring mechanical ventilation with either continuous positive airway pressure or endotracheal intubation. 27 Fractures of the first and second ribs historically have been associated with high-energy mechanisms of trauma and with aortic trauma.
However, several studies suggest no increased risk for aortic injury with upper rib, sternal, scapular, or thoracic spine fractures. 17,18,26,28 Lee et al.
17,18 found that the rate of thoracic aortic injury increased in a statistically significant but not a clinically meaningful degree in patients with rib fractures. 17,18Stawicki et al. 29 noted an increase in mortality associated with rising numbers of rib fractures, particularly in the elderly.
Overall, it is likely that rib fractures are a marker of high-energy trauma and morbidity from other injuries (including extrathoracic injuries), although in this study multiple rib fractures were independent predictors of mortality. 18,30 suggested that three or more rib fractures were an indication for transfer to a trauma center, because of increased mortality, mean injury severity score, mean hospital stay, mean number of intensive care unit days, and rates of liver and spleen injuries. Other studies have shown that pain from rib fractures is a significant cause of disability, with pain persisting well beyond 30 days in some cases.
Freedman, in, 2018 Rib FractureRib fracture was associated with old series of radiation, particularly with the use of orthovoltage radiation due to its giving a higher relative dose to bone than does modern megavoltage radiation. The incidence of rib fracture after breast conserving surgery and radiation in the 1980s and 1990s was reduced to approximately 1% to 2% or less. 51,53,93–95 In the UK START trial, enrolling from 1999 to 2002, the 1% to 2% of reported cases within 10 years included many with history of trauma or metastases. 76 The confirmed cases after imaging and further investigations was 0.3% or less.
Rib pain may not always be associated with abnormalities on imaging. Symptomatic rib fractures related to history of breast radiation may be treated with standard measures of pain medication and incentive spirometry. Recovery is usually within 6 to 8 weeks. Rib fractures ( Figures 5 and 6) are the most common traumatic thoracic injury occurring in almost 40% of thoracic trauma and typically affecting the 4th to 9th ribs ( Sirmali et al., 2003; Liman et al., 2003). Isolated rib fractures are uncommon, occurring in just 13% of all cases of rib fracture ( Sirmali et al., 2003). Traumatic rib fractures are usually associated with other injuries, with three-quarters of patients having concomitant pneumothorax, hemothorax, or hemopneumothorax ( Sirmali et al., 2003).
Motor vehicle accidents are the leading cause of rib fractures, with falls, assaults, and work-place injuries making up the remainder of cases, in decreasing order of frequency ( Sirmali et al., 2003; Liman et al., 2003). Multiple rib fractures are seen in stampede incidents in chaotic, overcrowded, and restricted areas.
Injuries involving the 1st and 2nd ribs are a marker of significant trauma and may be associated with injury to the great vessels ( Liman et al., 2003). Fractures involving the 9th to 12th ribs may be associated with laceration to underlying liver, spleen, or kidneys. Overall mortality secondary to rib fractures is reported to be between 2% and 6% in those patients surviving to hospital presentation, with 3% of all deaths directly attributable to pulmonary injury ( Liman et al., 2003; Sirmali et al., 2003; Brasel et al., 2006). Multiple bilateral anterior rib fractures sustained due to a fall from a height.Flail chest injuries occur where three or more consecutive ribs are fractured in at least two places resulting in a flail segment. Alternatively, injuries may also involve fractures of consecutive ribs with concomitant sternal fracture. Flail chest injuries have been reported to occur in approximately 6% of all traumatic rib fractures, and are associated with significant morbidity and mortality ( Sirmali et al., 2003).
Clinical features include chest wall deformity and paradoxical respiratory chest wall motion. This results in loss of intrathoracic volume with impaired respiration. Flail chest injuries most commonly are the result of blunt chest trauma, usually from motor vehicle accidents, with only occasional case reports describing such injuries secondary to penetrating trauma ( Dehghan et al., 2014; Gamblin and Dalton, 2002). Pneumonia, sepsis, and acute respiratory distress syndrome may complicate this condition ( Dehghan et al., 2014).
Flail chest injuries are reported to carry a mortality of approximately 20%, largely contributed to by associated intracranial, pulmonary, and abdominal injuries ( Sirmali et al., 2003; Liman et al., 2003; Dehghan et al., 2014). This is particularly true of associated pulmonary contusions and significant head injuries, which carry a worse prognosis ( Dehghan et al., 2014).Blunt thoracic wall injuries including multiple rib fractures, fracture of the sternum, and external thoracic wall bruising or abrasion are also seen following cardiopulmonary resuscitation. At autopsy, further signs of attempted resuscitation should be looked for. Perusal of the hospital case files and eliciting a clear history prior to conducting the autopsy is very crucial in proper interpretation of resuscitation injuries ( Fegan-Earl, 2005). Joseph Varon. Bisbal, in, 2008 Chest Wall TraumaRib fractures are the most common chest wall injury.
Rib fractures are an important indicator of underlying injury. Fractures of the first to third ribs are associated with injury to the great vessel and with bronchial injury, whereas lower rib fractures are associated with kidney, liver, and splenic lacerations. Flail chest occurs when three or more ribs are fractured in two places or in multiple fractures associated with sternal fracture. The clinical significance of flail chest varies, depending on the size and location of the flail segment and the extent of the underlying pulmonary contusion. Patients with severe hypoxemia require endotracheal intubation and PPV. 71, 72 Indeed, correction of flail chest occurs with the application of PPV. However, the clinician must observe for late development of pneumothorax, especially tension pneumothorax, in the mechanically ventilated patient.
73Sternal fractures can occur in the trauma patient and are associated with myocardial contusion, cardiac rupture and tamponade, and pulmonary contusion. 74 Early surgical fixation is often necessary; urgent surgery may be indicated when costosternal dislocations compromise the trachea or the neurovascular structures at the thoracic inlet. McKenzie III, in, 2018 Rib Fractures, Pneumothorax, and HemothoraxRib fractures are a fairly common problem, having been reported in 3% to 5% of the general population of neonatal foals and as many as 30% of foals presenting to a neonatal ICU.
Took a big opinion penalty for being a tyrant, and of course her father hates me, and he.is. Crusader kings 2 betrothal.
353 Fractured ribs can cause a number of traumatic insults to the thoracic viscera, including pulmonary contusions and lacerations of the lungs, major arteries, heart, or diaphragm. Pneumothorax, hemothorax, and diaphragmatic herniation may all occur as a result of these traumatic insults, and myocardial injury is typically fatal. Rib fractures can be single, but are often multiple, most often affecting adjacent ribs on one side of the chest. The most common site of injury is at the costochondral junction or immediately dorsal to it. 354 Flail chest, or paradoxic thoracic wall motion, may occur when multiple ribs are fractured, and the affected region will move inward during inspiration and outward during expiration, counter to the movements of the intact portions of the thoracic wall. Rib fractures are commonly found on physical examination by palpation of the fracture itself or by the detection of crepitus at the site of the fracture.
Auscultation may reveal grinding or “clicking” sounds in the area of the fracture as well. Confirmation of the diagnosis is best accomplished ultrasonographically because this modality is much more sensitive than radiography for this purpose. 355 Ultrasonography may also be used to document the presence of air, blood, or abdominal viscera within the thoracic cavity, although radiography may be helpful in this evaluation. Treatment depends on the structures involved and the severity of the complications observed. Most minimally displaced rib fractures, particularly those involving the costochondral junction, can be managed conservatively with stall rest and avoidance of pressure on the affected area when the foal is handled.
Mild to moderate pneumothorax may not require intervention, but if substantial air is presented within the pleural cavity it will cause respiratory distress and should be evacuated. Placement of an indwelling thoracic catheter will facilitate ongoing drainage. If multiple ribs are fractured, and particularly if sharp bony projections are exposed and threatening internal injury, then surgical repair may be indicated.
356 Hemothorax can be life-threatening because of pulmonary compression and/or severe blood loss anemia, and treatment should focus on addressing the primary cause of hemorrhage and patient stabilization and support. Matias Bruzoni MD, Thomas M. Krummel MD, in, 2012 Rib fractures and flail chestRib fractures are unusual in children because of the extreme flexibility of the osseous and cartilaginous framework of the thorax.
The upper ribs are protected by the scapula and related muscles, and the lower ribs are quite resilient. As such, rib fractures are present in only about 3% of children admitted with thoracic injury.
12 Predictably, children with more than one rib fracture are more likely to have sustained multisystem trauma; 13 crush and direct-blow injuries are the usual etiologic factors. Multiple fractures of the middle ribs are almost diagnostic of battered-child syndrome.Multiple rib fractures, resulting in destruction of the integrity of the thoracic skeleton, can cause the paradoxic “flail chest” motion ( Fig. The unsupported area of the chest moves inward with inspiration and outward with expiration; these paradoxical respiratory excursions inexorably lead to dyspnea ( Fig. The explosive expiration of coughing is dissipated and made ineffectual by the paradoxical movement and intercostal pain. In effect, the ideal preparation for acute respiratory distress syndrome—airway obstruction, atelectasis, and pneumonia—has been established.The clinical picture includes local pain that is aggravated by motion. Tenderness is elicited by pressure applied directly over the fracture or elsewhere on the same rib. The fracture site may be edematous and ecchymotic.
The clinical manifestations may range from these minimal findings with simple, restricted fractures to the severest form of ventilatory distress with a flail chest and lung injury. Chest radiographs demonstrate the extent and displacement of the fractures and hint at underlying visceral damage.Treatment of uncomplicated fractures requires pain control to allow unrestricted respiration. Displacement requires no therapy. With severe fractures, alleviation of pain and restoration of cough are important and can be provided by analgesics, physiotherapy, and intermittent positive-pressure breathing.
Thoracentesis and insertion of thoracostomy tubes should be done promptly for pneumothorax and hemothorax ( Figs. 75-3), and shock should be managed by appropriate replacement therapy and oxygen.Paradoxical respiratory excursions with flail chest must be promptly brought under control, sometimes requiring mechanical positive pressure ventilation to help prevent respiratory distress syndrome, which may be the morbid pulmonary complication.
In some cases, a thoracic epidural may be useful to provide appropriate analgesia and achieve effective ventilation. Immediate fixation is rarely indicated. Waldman, in, 2007 Signs and SymptomsRib fractures are aggravated by deep inspiration, coughing, and any movement of the chest wall. Palpation of the affected ribs may elicit pain and reflex spasm of the musculature of the chest wall. Ecchymosis overlying the fractures may be present ( Fig. The clinician should be aware of the possibility of pneumothorax or hemopneumothorax. Damage to the intercostal nerves may produce severe pain and result in reflex splinting of the chest wall, further compromising the patient's pulmonary status.
Failure to treat this pain and splinting aggressively may result in a negative cycle of hypoventilation, atelectasis, and ultimately pneumonia. Jacob MBBS MS (Anatomy), in, 2008Rib fractures can be fracture of a single rib or can be multiple fractures and are caused by direct blow on the rib or by a crush injury.
In a severe crush injury several ribs can fracture in front as well as behind producing a loose segment of chest wall disconnected from the rest. This is known as a ‘stove-in-chest’. The loose segment may show paradoxical movements during respiration i.e.
Moves inwards during inspiration and blows out during expiration. Stove-in-chest is a serious condition needing urgent intubation and positive pressure ventilation using a respirator as well as a chest drain.