THORACIC TRAUMA
RIB FRACTURE
Ahmed Marouf, MD
Consultant of General Surgery
Faculty of Medicine - October 6 University
Introduction
Nearly 25 % of trauma deaths are due only to thoracic injuries and
50 % of patients who die from polytrauma have significant thoracic
injury.
Thoracic trauma is fatal unless treatment is instituted rapidly.
RIB FRACTURE
ETIOLOGY
Direct trauma
Direct blow (e.g. FFH, MCA, ..)
Single / multiple ribs may be
fractured mainly at the site of
impact.
The broken ends are driven
inwards producing pleural and
lung injury.
Indirect trauma
Chest compression AP
beyond elasticity of ribs.
Ribsusually break at sites
of maximal stress (angles).
The broken ends are
driven outwards ->
uncommon visceral injury.
Muscular Strain
Muscular strain e.g. during
violent cough or lifting heavy
weight -> fracture at the ant
segment of a rib
Most common in elderly with
senile osteoporosis
Types
Simple Rib Fracture
Flail Chest
Simple Rib Fractures
Clinical Presentation
History of direct chest trauma ++
Localized pain, tenderness ± crepitus
Severe pain in multiple rib fractures -> limited chest
expansion -> dyspnea (esp in hemothorax/ pneumothorax)
Symptoms of associated injuries/ fractures in other parts of
the body.
General Examination
The patient may be dyspneic.
Signs of shock (neurogenic/ hypovolemic).
Search for associated injuries or fractures in other parts
of the body (head, abdomen, limbs,..)
Chest Examination
Inspection -> Localized areas of ecchymosis. External
wound may be present.
Palpation -> Localized tenderness and crepitus at the
site of the fractured rib.
Auscultation: Equal air entry on both sides in
uncomplicated cases.
Complications
Hemothorax
Pneumothorax
Lung contusion
Limited resp movement -> atelectasis and chest infection
Investigations
Plain CXR -> fractured ribs (number, site). It can also
detect possible hemothorax/ pneumothorax.
Abd US/ CT -> suspected injuries in other parts of the body.
Treatment
Management of shock (if present) by IV fluids
Strong analgesics (pethidine, NSAIDs) -> proper resp
movement.
Intercostal nerve block may be required for persistent
pain (anesthetic agent injection in intercostal spaces
above and below the fractured rib).
Elastic corset may be useful especially in elderly.
Flail Chest
Introduction
This type of ribs fracture occurs when ≥ 3 ribs are
fractured at 2 points on one side of the chest wall.
It is usually caused by crush injury to the chest as in
severe MCA.
Pathophysiology
The flail (Floating) segment moves paradoxically?
Paradoxical movement compromise ventilation (limit creation of –ve
intrathoracic pressure) -> marked interference with resp
efficiency -> hypoxia and CO2 retention.
Inspiration Expiration
Pathophysiology
Pendulum respiration: Rebreathing of air between the
healthy lung and the affected lung.
Mediastinal Flutter: (side to side movement) -> affected cardiac
action with decreased VR -> aggravation of shock
Clinical Presentation
History of severe chest trauma.
Marked chest pain.
Shortness of breath.
General examination
Signs of shock (neurogenic or hypovolemic).
Pallor / cyanosis
Associated injuries or fractures in other parts of the body
Chest Examination
Inspection:
Ecchymosis on the chest wall
Limited chest expansion on the affected side
The paradoxical movement may be evident.
Palpation: Tenderness and crepitus.
Auscultation: Decreased air entry on the affected side.
Complications
Respiratory failure
Hemothorax
Pneumothorax.
Investigations
Plain CXR -> flail chest ± associated hemo- / pneumothorax
ABG -> effect on respiration: decreased PO2 and
increased PCO2, ± decreased pH in severe cases.
Treatment
Strong analgesics ++
Initial stabilization by cotton gauze + compressive
bandage / elastic chest belt.
Endotracheal intubation + IPPV -> internal stabilization of
the flail segment in severe cases.
Surgical fixation of flail segment is not required unless there are
other underlying injuries requiring thoracotomy.
Physiotherapy is recommended.
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