Rib fracture

By:
Simon Peter Mollaneda
 Patient Profile

• R.P
• 51 years old/Male
• Filipino
• Married
• Roman Catholic
• Unemployed-On call Painter
• Linao, Talisay City, Cebu
• Admitted for the 1st time in this institution
• Source of data:
– Patient
• Reliability:
– >90%
 Chief Complaint
• Pain discomfort on Right chest radiating to
R shoulder
• Limitation of movement R shoulder
• Dyspnea on exertion
 History of Present Illness
• Few minutes PTA, patient was riding his
motorcycle in a steady pace in single lane
when suddenly another motorcycle
(NMAX) crossed his lane causing the
collision.
• Causing the patient to crash and hit his
chest part on the MC handle bar.
• No abdominal impact noted.
 PRIMARY SURVEY
• A: Patent airway
• B: Spontaneous breathing
• C: Capillary refill time < 2 seconds
• D: Glasgow Coma Scale = 15
• E: (+)Deformity on affected area,
tenderness noted
 SECONDARY SURVEY
• A: No allergies to food and drugs
• M: No maintenance meds
• P: No history of medical admissions
• L: 6:30 AM
• E:
– NOI: Motor Vehicular Accident
– POI: Tabunok, Talisay City, Cebu
– DOI: February 5, 2021
– TOI: 7:00 AM
 Past Medical History
• Non-Diabetic
• Non- Hypertensive
• Non- Asthmatic

• No history of surgical operations

• FDA: Amoxicillin
 Family History
• No known heredofamilial disease
 Social History
• Non-smoker
• Occasional alcoholic beverage drinker (beer)
 Physical Examination
• General Survey:
• Patient examined awake, conscious, coherent,
ambulatory but weak, dyspnea on exertion, (+)
LOM, R shoulder
• V/S:
• Temp: 36.9˚C
• RR: 18
• PR: 88 bpm
• B/P: 120/80 mmhg
• O2 sat: 98%
• Height
• 160 cm
• Weight
• 64kg

BMI: 25.6 kg/m2

• SKIN
– Inspection
• Skin is brown in color
• No Excoriation
• No cyanosis nor jaundice
• No hyperpigmentation
– Palpation
• Skin is warm
• Good turgor
• + tenderness noted, R thoracic area
• HEENT
• Head & Scalp
Inspection
• Black and evenly distributed hair
• No nits, flakes, or dirt on the scalp

Palpation
• Hair is coarse
• No mass
• Eyes
– Inspection
• Eyebrows symmetric and evenly distributed
• No ptosis
• Anicteric sclera
• Pinkish palpebral conjunctiva
• Ears
– Inspection
• Symmetric auricles with no lesion
• No deformities and cutaneous lesions
• Pinna is at the level of the inner and outer canthus of the
eyes
• No ear discharge

– Palpation
• Tenderness not noted
• No lump
• Nose
– Inspection
• Symmetric external nose
• Nasal septum at midline and intact
• Pinkish nasal mucosa
• No alar flaring
• No bleeding nor discharge

– Palpation
• No sinus tenderness
• Nose bridge smooth and intact with no tenderness
 
• Mouth and Throat
– Inspection
• Moist and pink lips
• No crack, ulcer nor blister
• Pinkish oral mucosa and gums
• Tongue at midline
• Uvula at midline
• Non-hyperemic and swollen tonsils
• Neck
– Inspection
• No mass
• Trachea at midline
• Neck veins not engorged
– Palpation
• No lymphadenopathy
• Thyroid gland not palpable
– Auscultation
• Bruit sounds not heard
• CHEST AND LUNGS
• Anterior and Posterior Thorax
– Inspection
• Slightly deformed area, injured site
• (+) Minimal chest expansion, R

– Palpation
• (+) chest tenderness, R
– Percussion
• Failed to assess. Patient claimed pain discomfort on area
– Auscultation
• Normal breath sounds
• CARDIOVASCULAR SYSTEM
– Inspection
• Adynamic precordium

– Palpation
• No palpable heave or thrill
• No tenderness

– Auscultation
• Regular heart rate and normal rhythm
• Good S1 and S2 sound, S2 heard greater at the base, S1 heard
greater at the apex
• ABDOMEN
– Inspection
• Flat
• Umbilicus at midline
• No visible veins
• No visible peristalsis and pulsation
• No rash or hyperpigmentation
– Auscultation
• Normoactive bowel sounds
• No bruits

– Percussion
• Tympanitic at all quadrants

– Palpation
• Non tender
• No organomegaly
• GENITOURINARY TRACT
– Inspection
• Grossly male
• No discharge
• No lesion
– Palpation
• No lesion
• PERIPHERAL VASCULAR SYSTEM
– Inspection
• Pinkish nailbeds
• capillary refill of <2 seconds
• Cyanosis not noted
• No edema

– Palpation
• Upper and lower extremities are warm to touch
• Strong peripheral equal pulses
• MUSCULOSKELETAL SYSTEM
– Inspection
• No joint deformities,
• No signs of infection and inflammation
• No deformities
• No swelling of joints
• Full range of motion

– Palpation
• Good muscle tone
• No muscular atrophy
• No tenderness on shoulders, arm, knees or hips
• NEUROLOGIC EXAMINATION
– Mental Status:
• awake and conscious
• oriented to place, person and time
– Cerebrum
• Appearance: in pain, aware of the situation
• Affect: Appropriate for the situation, anxious 
– Cerebellum
• Coordinated movements
• No ataxia or tremors
– Motor
• (-)spasticity
• (-)flaccidity
• Good muscle bulk and tone
• Normal range of motion
• Motor strength of 5/5 – normal, full strength
– Sensory
• Change of facial expression and withdrawal from
pain stimulus
• Responds to light touch
– Cranial Nerves
• I - Not tested 
• II, III- Pupils are equally round and reactive to light and
accommodation;intact direct and consensual pupillary light
reflex
• III, IV and VI- intact extraocular muscle function
• V
Motor: Intact temporal and masseter strength; clenches teeth
Sensory: Able to react to light touch
• VII – no facial asymmetry; Can close both eyelids,
changes in facial expression
• VIII - intact and able to respond when called by his
name
• IX and X
Able to swallow water
• XI
Can turn head on both sides
Can shrug shoulders with limitations
• XII
Tongue protrusion at midline, no deviation
 Salient features
HISTORY Physical Examination

NOI: MVA (+)Dysnea on exertion

TOI: 7:00 AM

DOI: 02/05/2021

POI: Tabunok, Talisay City, Cebu

(+) Tenderness , R chest
(+) Slightly deformed, injured site, R
(+) Cracking/snapping sensation
 Admitting Impression
• Blunt chest trauma
• R/I Multiple rib fracture, Right
 Differentials
Rule in Rule out

Hemothorax (+)Dyspnea (-) decreased breath

(+) Depressed deformity sounds
(+)Requires blunt trauma

Simple Pneumothorax Close wound (-)decreased breath

(+)Dyspnea sounds
(+) Depressed deformity
(+)Requires blunt trauma
 Course in the Wards
HD 1 (2/5/21)
S> (+)Pain in the area of injury site, (+) dyspnea, (+) Limited movement, R arm, (-)
abdominal painm, (-) fever, (-)cough, (-)colds

O> Ambulatory, awake, alert, in respiratory distress.

(+)Depressed area, injured site
VS: BP: 120/80 HR: 88 RR: 18 T:36.9C O2- 97-99%

A> Multiple rib fracture, 4th and 5th ribs secondary to MVA

P>Admit
>Further observation
>Venoclysis with PLR 1 L @ 30gtts/min
>DAT w/ strict aspiration precaution
Medications:
1. Tramadol 50 mg IVTT now then PRN for breakthrough pain
2. Ketorolac 30 mg IVTT q 8 H
Labs: CBC, UA, Blood typing, HBsAG
> CXP-AP bucky now then repeat CXR 6H post X ray.
HD 1
Laboratory results(2/5/21)

• CBC DIFFERENTIAL COUNT

– WBC= 12 NEUTROPHILS 77
– Hemoglobin= 173 LYMPHOCYTES 8
– Hematocrit=47 MONOCYTES 5
– MCV=82 EOSINOPHILS 0
– MCH=29.9 BASOPHILS 0
– RBC COUNT=5.8
– MCHC=37 Blood type: O+
– RDW=13.1 HBsAg: NR
– PLATELET=325
Chest X-ray AP Bucky view w/
Shoulder ,L -APL (2/5/21)
Repeat CXR AP bucky
 Course in the Wards
HD 2 (2/6/21)
S> Verbalized improvement in pain

O> Ambulatory, awake, alert, conversant, improving motion, NIRD

C/L : Equal chest expansion, Clear breath sounds,
VS: BP: 130/90 HR: 72 RR: 20 T:36.4C O2- 98%

A> Multiple rib fractures, R, 4th and 5th ribs

P>For CXR PA view now

> Continue incentive spirometry
> Discontinue Ketorolac and Tramadol
> Start Celecoxib 200 mg capsule PO BID
> Consume and discontinue IVF
Chest X-ray Post CTT
insertion(2/6/21)
 Course in the Wards
HD 3 (2/7/21)
S> (+)Tolerable pain in the injured area, (-) dyspnea, No other complaints noted

O>Ambulatory, awake, alert, conversant, NIRD

VS: BP: 150/100 HR: 90 RR: 71 T:36.3C O2- 99%

A> Multiple rib fractures, R, 4th and 5th ribs

P>Start Tramadol 50mg / tablet PO TID with BP precaution.

> For discharge once with adequate pain control.
>Continue incentive spirotmetry
 Course in the Wards
HD 3 (2/8/21)
S> (+)Tolerable pain in a injured,(-) dyspnea, (-) epigastric pain,

O>Ambulatory, awake, alert, conversant, improving motion, NIRD

C/L : Equal chest expansion, Clear breath sounds,
VS: BP: 170/100 HR: 74 RR: 21 T:36.6C O2- 99%

A> Multiple rib fractures, R, 4th and 5th ribs

P>May go home
>Take home meds:
1. Celecoxib 200 mg / capsule po BID PRN for pain.
2. Tramadol+Paracetamol 37mg/325mg/tabPO TID for pain
>Continue Incentive spirometry 2 cycles per hour during waking hours
>Start Clonidine 75mcg , 1 tablet SL now, repeat BP 15-30
> Ketorolac, 30 mg IV now
> Ff-up at OPD IM service Re: Elevated BP
Repeat CX AP view 3/15/21
 Final Diagnosis

• Multiple rib fractures, 2nd, 4th and 5th

ribs, Right, Secondary to Motor
Vehicular Accident
• Pulmonary contusion, R
Discussion
 ANATOMY
• Thorax

Lies between the neck and abdomen,

encasing the great vessels, heart, and lungs
and provides a conduit for structures passing
between the head and neck superiorly and the
abdomen, pelvis and lower limbs inferiorly.
 Functional anatomy
• Functions as:
– Protection: of vital structures
– Support: muscular support of upper limb
– Conduit: provides Sup. and Inf. Thoracic apperture
and a central mediastinum
– Segmentation: hallmark of the vertabrate body plan.
– Breathing: essential for expanding the thoracic
cavity to facilitate entry of air into lungs
– Pumping blood: contains heart which pumps blood
through the pulmonary and systemic circ.
THORACIC CAGE (Ant. And Post. View)
INTERCOSTAL VESSELS AND NERVES
INTERCOSTAL VESSELS AND NERVES
 Lymphatic Drainage
1. Axillary vein group (lateral)
– 4-6 nodes
– Medial or posterior to the vein
– Receive most of the lymph drainage from the upper extremity
2. External mammary group (anterior or pectoral)
– 5-6 nodes
– Lie along the lower border of the pectoralis minor muscle contiguous with
the lateral thoracic vessels
– Receive most of the lymph drainage from the lateral aspect of the breast
3. Scapular group
– 5-7 nodes
– Lie along the posterior wall of the axilla at the lateral border of the scapula
– Receive lymph drainage from the lower posterior neck, posterior trunk,
and posterior shoulder
 Lymphatic Drainage
4. Central group
– 3-4 nodes
– Embedded in the fat of the axilla, immediately posterior to the
pectoralis minor
– Receive drainage from the axillary vein and external mammary
5. Subclavicular group (apical)
– 6-12 nodes
– Posterior and superior to the upper border of the pectoralis minor
– Receive drainage from all of the other groups of axillary lymph nodes
6. Interpectoral group (Rotter’s lymph nodes)
– 1-4 nodes
– Interposed between the pectoralis major and minor muscles
– Receive drainage directly from the breast
LUNGS
Muscles of INSPIRATION and
EXPIRATION
Management
 Initial management of seriously injured
patients
• Primary survey
• Secondary survey
• Definitive care
• Tertiary survey
 Main causes of Chest Trauma
• Blunt trauma
– Blunt force to chest

• Penetrating Trauma
- Projectile that enters chest cuasing
small or large hole
Rib fracture
 Rib fracture
• Single or Multiple
• Usually after blunt trauma
• Fracture of First Rib is associated with
injuries to great vessels, important nerves
of the upper limb.
• If 8,10,11,12 Ribs involved, be suspicious
for liver or spleen or kidney injuries
 Treatment
• Effective analgesia
– Rib blocks with .25% bupivacaine hydrochlride
– Epidural anesthesia is reserved for multiple segmental
fractures

• Pulmonary toilet
- Patient is asked to cough, breathe deeply since the patient is
ussually unable to do so resulting in poor clearance of secretions.

• Internal fixation with plates and screws

- For severe injuries
 Signs and symptoms
• Pleuritic chest pain
• Rapid shallow breathing
• Atelectasis
• Hypoxemia
 Pulmonary Contusion

• Sudden blow or blunt injury to the chest

– Concussive and compressive force is most
important cause.
• Crushing and bruising of the lung parenchyma
• CXR findings not significant initially
• CT with contrast is confirmatory
 Signs and symptoms
• Hemoptysis, Dyspnea, Cough, Chest wall
abrasion, Echymosis.

• Concurrent PULMONARY CONTUSION is

noted up to 35% of patient

• Patient who sustain more than 6 rib fx have

pulmonary morbidity rates of >50% and
overall mortality rates of >20%.
 Treatment
• Close monitoring and frequent clinical re-
evaluation are warranted

• O2 administration
 Hemothorax
• Follows blunt injury
• Occurs when pleural space fills with blood
• Usually occurs due to lacerated blood
vessle in thorax mainly Intercostal and
Internal Mammary Vessels.
• As blood increases, it puts pressure on
heart and other vessels in chest cavity
• Each Lung can hold 1.5 L of blood
 Signs and symptoms
• Anxiety/ Restlessness
• Tachypnea
• Signs of shock
• Frothy, bloody sputum
• Diminished breath sounds on affected side
• Flat neck Veins
 Treatment
• ABC’s with C-spine control
• General shock care due to blood loss
• CTT
• Thoracotomy - if more than 1500 ml of
blood drains initially, or on going
hemorrhage of 200-250 ml/hr over 3 H.
 Pneumothorax
• Air in the pleural space resulting in partial
or complete collapse of the lung space.

Types:
• Tension Pneumothorax
• Open Pneumothorax
 TENSION PNEUMOTHORAX
• Patient manifesting distress and hypotension in
combination with any of the following physical signs:
- Tracheal deviation away from the affected side
- Lack of or decreased breath sounds on the
affected side
- Subcutaenouse emphysema on the affected
side
- May have distended neck veins
- Presence of HYPOTENSION
 Signs and symptoms
• Severe dyspnea
• Tachypnea
• Distended neck veins
• Hyperresonance
• Absent breath sounds on affected side
• Hypotension
• Tracheal deviation
 Treatment

• Needle decompression
– Large bore needle (14-gauge)

• CTT insertion
Treatment
 Open Pneumothorax
(Sucking chest wound)
• Occurs with full-thickness loss of the chest
wall, permitting free communication
between the pleural space and the
atmosphere.
• Causes the lung to collapse due to
increased pressure in pleural cavity
 Signs and symptoms
• Hypoxia and hypercarbia
• Sudden sharp pain
• Subcutaneous Emphysema
• Decreased breath sounds on affected side
 Treatment
• Temporary management:
• Temporary management -
covering the wound with an occlusive
dressing that is taped on 3 sides.

• Definitive management:
• Closure of the chest wall defect and tube
thoracostomy remote from the wound.
 Treatment
• Diagnostic
CXR standing
Smaller pneumothorax may need
expiration CXR or CT
• Other expectant management
• Observation = Small pneumothorax = Asymptomatic
• Pleurectomy
• Pleurodesis-sclerosing agent
• Surgery
 Flail Chest
• Occurs when 3 or
more contiguous
ribs are fractured in
at least two
locations.
 Signs and symptoms
• Painful breathing • Crepitus
• Paradoxical chest • Diagnosis is purely
movements clinical
• Rapid, Shallow • CXR, ABG’s can
respiration, be done to confirm
Dyspnea
• Brusing, swelling
 Treatment
• ABC’s with C-spine control as indicated
• High flow oxygen
• Adequate analgesia
• Intraplueral local analgesia
• Observe the patient for development of
Pneumothorax.
– If Tension Ptx develps, Needle decompress affected
side.
• Surgery- Internal operative fixation
CTT INSERTION
• Thank you for listening!