 Sternal and Rib Fracture

 Flail Chest
 Penetrating Trauma
Sternal and
Rib Fracture
Sternal fractures are most
common in motor vehicle
crashes with a direct blow to
the sternum via the steering
wheel.

Rib fractures are the most

common type of of chest
trauma with blunt chest
injury.

Fractures of the first 3 ribs-

are associated with injury to
the subclavian artery or
vein.

Fractures of the lower ribs-

are associated with injury to
the spleen and liver, which
Clinical Manifestation
Sternal Fracture: Rib Fractures:

 Chest pain  Severe pain

 Overlying tenderness  Point tenderness
 Ecchymosis  Muscle Spasm
 Crepitus
 Swelling
 Possible chest deformity
Assessment and
diagnostic findings

•The patient must be

closely evaluated for
underlying cardiac injuries.
•A crackling, grating sound
in the thorax (subcutaneous
crepitus) may be detected
with auscultation.
•The diagnostic workup
may include a chest x-ray,
rib febris of a specific area,
BCG, continuous pulse
oximetry, and arterial blood
gas analysis.
Pathophysiology
 Medical and Nursing Management
Medical management
 Medical management is directed toward
relieving pain, avoiding excessive activity,
and treating any associated injuries.
 Surgical fixation is rarely necessary unless
fragments are grossly displaced and pose a
potential for further injury. Sedation is used
to relieve pain and to allow deep breathing
and coughing.
 Alternative strategies to relieve pain include
an inter-coastal nerve block and ice over the
fracture site.
 A chest binder may be used as supportive
treatment to provide stability to the chest
wall and may decrease pain.
 Epidural analgesia, patient-controlled
analgesia (PCA), or nonopioid analgesia
Nursing management
 Provide the patient with adequate analgesia coupled
with meticulous respiratory care in order to prevent
complications such as atelectasis and pneumonia
 The main problem for patients with multiple
fractures of the ribs is pain from the fracture. The
consequence of this is reflex inhibition of movement
of the affected part of the chest wall, resulting in
poor ventilation of the lung.
 The consequence may be atelectasis, hypoxia (lower
than normal levels of oxygen) and retention of
secretions. To minimise these problems, the patient
(if conscious and compliant), is taught the active
cycle breathing technique.
 This involves deep breathing thoracic expansion
exercises, relaxed breathing and a forced expiratory
technique. Postural drainage, supported cough and
incentive spirometry may be initiated at the same
time.
Flail chest
Flail chest is frequently a
complication of blunt chest
trauma from a steering
wheel injury. It usually
occurs when three or more
adjacent ribs (multiple
contiguous ribs) are
fractured at two or more
sites, resulting in free-
floating rib segments.
Clinical Manifestation
 Paradoxical movement:
 When someone with this injury inhales and the rest of the chest
expands, a flail segment will sink inward. On the other hand,
when the rest of the chest contracts on an exhale, the flail
segment bulges outward.
 Severe chest pain
 Difficulty breathing
Assessment and
diagnostic findings

Physical Examination- for

unusual movement of the
chest when breathing.

Result: Chest wall and

underlying tissue moves in a
paradoxical motion.

Chest X-ray- to confirm

diagnosis Chest X-ray-
punctured blood vessel or
contusions on the lungs, for
example, are solid
indications of flail chest.
Pathophysiology
 Medical and Nursing Management
Medical management Nursing management
 Thorax stabilization
 Monitor respiratory rate, depth, and
 Using chest straps to reduce paradoxical
character.
movement of flailing chest wall.  Monitor serial chest x-rays, ABG analysis,
 Patients without breathing difficulties pulse oximetry, and bedside pulmonary
 oxygen conventional hemostasis monitoring.
 pain medications  Auscultate the patient’s lungs
 mucolytic drugs  Provide ventilatory support
 necessary fluid resuscitation
 Monitor fluid intake
 hormone therapy
 Serious breathing difficulties or in coma
 Clear airway and secretions from the lungs
 Endotracheal intubation or tracheostomy -to
 Administer analgesics as ordered
provide mechanical ventilator support
 Fluid and blood infusion therapy- given for
patients with combined shock
 Thoracic drainage treatment. given for patients
with combined pneumothorax
Medical and Nursing Management cont.
Medical management Medical management
 Surgical Fixation
 Surgical rib fixation
 the fractured ribs were stabilized and
fixed by using a claw-type titanium
plate that was cut to the desired length
 Analgesic pain medications
 narcotics
 intercostal nerve blocks
 epidural spinal anesthesia
Penetrating Trauma

 Any organ or structure within the chest is potentially

susceptible to traumatic penetration. These organs include
the chest wall, lung and pleura, tracheobronchial system,
esophagus, diaphragm, and major thoracic blood vessels,
heart and other mediastinal structures.

 Common injuries include: pneumothorax and cardiac

tamponade.
Clinical Manifestation
 Chest pain
 Shortness of breathing
 Ecchymosis
 Respiratory distress
 Hypotension
 Neck vein distention
 Decreased breath sounds
Assessment and diagnostic findings
 Start with airway assessment and evaluate the airway by
listening for air movement and watching for chest
movement.
 Spinal immobilization should be maintained throughout the
assessment of gunshot wounds, as vertebral fractures or
spinal cord injuries may be present.
 assess for spontaneous breathing, quality of the breathing,
chest rise and fall, skin color, respiratory rate, and pattern.
Restlessness, tachypnea, cyanosis, and diminished breath
sounds are indicative of respiratory derangements.
 Chest X-ray, focused sonography, and computed
tomography are standard diagnostic tools.
Pathophysiology
 Medical and Nursing Management
Medical management
 The objective of immediate
 The nurse should assess the following:
management is to restore and maintain
cardiopulmonary function.
 After an adequate air-way is ensured
and ventilation is established,
examination for shock and intrathoracic
and intra-abdominal injuries is
necessary.
 Diagnostic workup includes:
 Chest x-ray
 Chemistry profile
 ABG analysis
 Pulse oximetry
 ECG
 Blood transfusion
Nursing management
 Respiratory:
 Dyspnea
 Respiratory distress
 Cyanosis of mouth, face, nail beds
 Tracheal deviation
 Audible air escaping from chest wound
 Decreased breath sound on the side of injury
 Decreased oxygen saturation
 Frothy secretions
 Cardiovascular:
 Rapid, thready pulse
 Decreased blood pressure
 Narrowed pulse pressure
 Distended neck veins
 Chest pain
 Dysrhythmias