T 98.9 P 90 BP 148/76 46 YOM with no reported O2 99% RR 16 chronic medical problems presents after mechanical Gen: WDWN fall onto his right side. He CV: RRR, no m/r/g is complaining of right Pulm: Lungs CTA bilat, sided flank/chest pain with BBSE, on examination deep inspiration. At of the chest wall the presentation he is patient is tender to awake/alert in no palpation over soft respiratory distress. He has been otherwise well free of tissue swelling and other injury or illness. ecchymosis in the right lower chest wall in the Abd: s/nt/nd
PA lateral film of right ninth rib CT from the same patient in the PA andfracture. No PTX was present lateral films above. This clearly shows the rib displacement near the liver on the right
Oxygen IV Fluids Adequate analgesia (with NSAIDs and opioid analgesics) and pulmonary toilet are the mainstays of treatment Consider intercostal nerve blocks for more adequate pain control Inpatient criteria: are elderly have preexisting pulmonary disease or significant comorbidities that would impair healing in an outpatient setting. Flail chest injuries As above including strong consideration of ventilatory support if: 3 or more associated injuries severe head trauma comorbid pulmonary disease age > 65 yrs. fracture of 8 or more ribs
Diagnosis Rib fractures have the appearance of an abrupt discontinuity in the smooth outline of the rib. A lucent fracture line may be seen. A common pattern for evaluating the ribs is to examine the posterior portions of the ribs first, then the anterior portions, and finish by examining the lateral aspects of each rib. If you see an abnormality, follow that rib in its entirety. If it is necessary to exclude a rib fracture, oblique rib detail films should be obtained. Up to 50 percent of rib fractures (especially those involving the anterior and lateral portions of the first five ribs) may not be apparent on x-ray. A rib fracture is a CLINICAL diagnosis Oblique films can be obtained to better define area of concern. The principal diagnostic goal with clinically suspected rib fractures is the detection of significant complications: pneuomothorx, hemopneumothorax, pulmonary contusion, major vascular injury, etc.. Most common location of rib fracture is posterior in nature
Significance of rib fracture The pain of rib fractures can greatly interfere with ventilation. Admit patients with fractured ribs for at least 24 to 48 h if they cannot cough and clear their secretions adequately, especially if they are elderly or have preexisting pulmonary disease. Fracture of the upper three ribs is associated with an increased risk of significant injury (often vascular) because of the excessive force needed to fracture these ribs. Fracture of the lower three ribs can be associated with liver or spleen injury Rib fractures in children should raise suspicion for child abuse given the compliance of the pediatric rib and the force needed to fracture one.
Left 7th posterior rib fracture in Right first rib fracturea pediatric patient
Flail Chest. Radiograph at left and CT at right demonstrate multiple ribfractures (white arrows) with some ribs fractured in two or more places (see CTscan). There is also a pulmonary contusion (red arrow), subcutaneousemphysema (yellow arrows) and a fracture of the left transverse process of thevertebral body imaged on the CT scan