Rib fracture
introduction
One area in surgery that is not easy to deal with is rib fractures.
A rib usually breaks under direct or indirect Violence on the Rib cage (thorax).
Depending on the force, direction and extent of the force acting, ribs in different ways break, which in turn has an impact on symptoms, therapy and accompanying complaints.
The Measure of severity A rib fracture can range from one simple fracture in the case of light violence (e.g. too strong cough in weak bone, like for example osteoporosis), which in some cases even go hand in hand with no impairment of the quality of life multiple fractures on a rib up to so-called Serial rib fractures (Breaks of more than three ribs), which develop when the thorax is subjected to massive violence and which then become one Hemothorax and or Pneumothorax can lead.
The biggest problem with rib fractures is one Impairment of breathing mechanicsbecause with every inhalation and exhalation, the ribs, as the bony corset of the thorax, must synchronize with the breath.
definition
A Broken rib (Rib fracture) refers to a fracture of the cartilaginous or bony Part of a rib.
One distinguishes one simple rib fracture (a breaking point where the two fragments are not shifted against each other) from one Separation break (Fracture at the transition from cartilaginous to bony rib tissue) and one Rib fracturewhere a rib shows multiple breaks.
A Serial rib fracture (Rib series break) denotes simultaneous fractures of at least 3 adjacent ribs.
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My name is dr. Nicolas Gumpert. I am a specialist in orthopedics and the founder of .
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In order to be able to treat successfully in orthopedics, a thorough examination, diagnosis and a medical history are required.
In our very economic world in particular, there is too little time to thoroughly grasp the complex diseases of orthopedics and thus initiate targeted treatment.
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The aim of any treatment is treatment without surgery.
Which therapy achieves the best results in the long term can only be determined after looking at all of the information (Examination, X-ray, ultrasound, MRI, etc.) be assessed.
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A rib fracture (rib fracture)
B - pneumothorax (collapsed lung)
C - rib series break
D - broken rib
(Broken ribs)
- Collarbone - Clavicle
- Rib - Costa
- Ribs 1-7 (true ribs) -
Costa 1-7 (Costae verae) - Costal cartilage -
Cartilago costalis - Ribs 11
(rudimentary ribs) -
Costa 11 (Cost. fluctuantes) - Ribs 8-10 (false ribs) -
Costa 8-10 (Costae spuriae) - Sternum handle -
Manubrium sterni - Right lung -
Pulmodexter - Sternum body -
Corpus sterni - Left lung -
Pulmo sinister - Sword extension -
Xiphoid process - Ribs 12
(rudimentary ribs) -
Costa 12 (Cost. fluctuantes) - Costal arch -
Arcus costalis
You can find an overview of all Dr-Gumpert images at: medical illustrations
Symptoms
The Symptoms of rib fractures depend on the Number and location the fractured ribs.
In the case of a simple, uncomplicated rib fracture, there is usually only the Pain over the affected area. The pain is breath dependent, he takes in breathing, deep breathing and especially cough because the chest and ribs expand.
Another characteristic of the rib fracture is a local tenderness and in some cases a noticeable one Crepitation (Rub the resulting fracture surfaces).
One runs under each rib Nerve / vascular network. Is this through the fractured rib injured, it can lead to the local (localized) hematoma as well Intercostal neuralgia come.
The Intercostal neuralgia denotes a stabbing to pulling one Pain in the intercostal area, the belt-shaped affect the sensitive area of the injured nerve and are in turn aggravated by movement, breathing, straining, and coughing.
Due to the breath-dependent pain Elderly patients minimize their breathing and flatten these.
This leads to an insufficient supply of the lungs and consequently to poorly ventilated lung areasin which are now Germs collect and grow better.
So it happens as a late consequence of Broken rib to lung infection (pneumonia).
At Serial rib fractures to a greater extent, the Significantly restricted breathing become. If the wall of the chest becomes unstable due to the multiple fractures (so-called. Unstable thorax) it can lead to the development of paradoxical / inverse breathing with subsequent respiratory insufficiency.
The chest wall behaves in the opposite way to the natural state, i.e. it contracts when you inhale and expands when you exhale, as the ribs can no longer serve as a counter-bearing. The lungs can no longer fill up adequately with fresh oxygen; the patient has to do this as quickly as possible intubated and be ventilated.
Other accompanying symptoms can be lung contusion, hemato- or pneumothorax.
As Lung contusion is a contusion of the lungs that is associated with the Small vessels ruptured in the lung and with the following Bleeding into the lung tissue goes hand in hand. As a result of the lung contusion, there is in turn insufficient ventilation of individual lung areas.
It comes to Injury to larger vessels and bleeding into the gap between the ribs and the pleura, the so-called Pleural space, it comes to the formation of a Hemothorax. Pressure builds up on the lungs, they can no longer develop properly and breathing is severely restricted.
(Please also read our article on this Hemothorax)
The same symptoms arise with Pneumothorax, only that with this no blood, but air in the area between the lung membrane (Pleura) and Peritoneum got. It does this by injuring the lungs from the sharp fracture end of a rib.
causes
The main causes of rib fractures are almost always blunt violence on the Rib cage, whereby the extent and severity of the fractures is in relation to the severity of the force.
Rib fractures can result from punches, falls, traffic accidents with violent effects on the chest and the like.
Is there a previously known reduction of the Bone density by osteoporosis or similar diseases, so-called 'Minor trauma " lead to rib fractures.
These are very minor external or internal forces of violence that would not have led to a fracture under normal bone conditions, such as a strong cough, non-violent touching of the thorax, etc.
diagnosis
The diagnosis of rib fractures is usually quite easy to make.
The main symptom here is the almost always present chest wall pain, which worsens depending on the breath.
In the patient survey (anamnesis), younger patients without a change in bone density (e.g. due to osteoporosis) have had a blunt force on the chest in the near past.
In older patients with known bone density loss, a strong cough is sometimes enough to break one or more ribs.
If a rib fracture is suspected, an X-ray image in two planes must always be taken to confirm the diagnosis and to exclude accompanying symptoms such as a pneumothorax.
Read more on the topic: Chest x-ray (chest x-ray)
If symptoms exist, concomitant diseases such as vascular injuries, nerve injuries, and injuries to the windpipe must be excluded.
These can manifest as blood loss, bleeding into the lungs with coughing up blood, loss of sensitivity and / or motor skills in the upper extremities or the chest, or problems with breathing.
Depending on the complaints, there is also a representation of the vessels (Angiography) or a CT is indicated.
If the fracture is in the lower ribs, internal organs such as the spleen, liver or kidney can be injured. This can be investigated using ultrasound diagnostics.
therapy
The Rib fracture therapy their severity is adjusted. Exists in the patient simple broken rib, which goes hand in hand with no major restrictions or complications, is usually enough "conservative therapy out.
Here the patient is adjusted with painkillers so that the To breathe and the inevitable daily movements no burden represent more. Of course, this should be done with an existing rib fracture did not do sports and big moves, especially that Lifting heavy objects and loads be avoided.
To avoid insufficient ventilation of individual lung areas, a targeted breathing training by forced exhalation against resistance Pain therapy be performed. This is part of the physiotherapeutic Standard repertoire. Does it come to lung infection, is used here accordingly Antibiotics and anti-inflammatory drugs.
If there is an injury to blood vessels or the lung membrane, a hematoma or Pneumothorax the accumulated blood or air must be removed by means of a drainage be derived.
As drainage a hose system is referred to here, which with a Vacuum pump connected is inserted into the thoracic wall and so sucks air or blood out of the so-called pleural space.
The drainage is kind of Bülau or Monaldi created.
A Bülau drainage is placed in the 4th or 5th intercostal space (space between the ribs) in the middle axillary line (in the middle of the armpit). Here the thorax is opened with a small hole, a tube is inserted into the chest wall, the inner end towards the head (in the case of a pneumothorax, since air collects at the tip of the lung) or diaphragm (in the case of a hemothorax, as blood collects at the base of the lungs) and the tube is fixed to the chest wall with a suture.
At a Drainage according to Monaldi the access is in the second intercostal space in the Medioclavicular line placed. This is the vertical extension of the center of the Collarbone.
This point is more accessible and the diameter of the access is smaller, which is a less trauma means for the patient, but with one lower effectiveness goes hand in hand.
Drainage according to Bülau is therefore standard.
If there is a pneumothorax or hemothorax, the follow-up must be carried out regular x-rays of the affected area.
For more information on the different types of drainage, please also read our corresponding main article: Chest drain
In rare, severe cases it exists with serial rib fracture also the indication for acute surgery.
This is given when the rib is broken internal organ injuredto use it for profuse bleeding comes, the lungs are injured by a piece of rib, there is a severely displaced fracture or an unstable thorax (see above) has occurred.
Here is the Chest wall by Osteosynthesis stabilized, so the ribs back to their original position brought and bonded with metal and stabilized.
An injury to internal organs or larger vessels must be specially treated, usually the injured areas are closed using special suturing techniques.
For more information, also check out our main article: Rib fracture treatment
Healing time
The duration of healing also adapts to the severity of the injury and the accompanying illnesses.
In general, broken ribs take a little longer than other broken bones to heal completely, as they cannot be permanently immobilized because they are needed for breathing and for most everyday movements.
If simple fractures in other parts of the body only need approx. 6 weeks to heal without symptoms, a simple rib fracture takes approx. 12 weeks until normal physical exertion without pain is possible.
Only during these twelve weeks are the two opposing fracture surfaces created by the fracture through giant phagocytes, so-called Macrophages, reduced. A first bone substitute material, the callus, is then created in its place.
This serves to bridge the fracture for the first time, but is nowhere near as hard and resilient as actual bone tissue. The bridge connection of the callus is completed in 3-4 weeks for simple, uncomplicated rib fractures. After this time there is already a significant decrease in the patient's pain and discomfort.
Following the callus formation, the body builds up through bone-forming cells that Osteoblasts, the callus material into hard, normal bone tissue (secondary healing of the fracture). It takes up to 12 weeks for a continuous costal arch to mature.
The time it takes to heal naturally increases with the severity and number of broken ribs. An accompanying hemothorax or pneumothorax usually heals in 7-10 days. After the pleural space has been seen to be empty of blood or air in the X-ray, the drainage tube is clamped with a clamp, one waits two days to see whether a spontaneous recurrence does not occur and, if it does not occur, the drainage is removed after the second day of observation.
forecast
The forecast for broken ribs is usually very good.
Uncomplicated, simple rib fractures usually heal without surgical intervention completely and without leaving any discomfort out.
Are concomitant diseases such as pulmonary contusion, haematous or Pneumothorax or if the unstable thorax is recognized and treated in good time, the healing process is extended, but even these patients recover completely.
Broken ribs are dangerous only in the form of Serial rib fractures, huge Vascular and organ injuries and under training the inverse breathing if the thorax is unstable, these are not recognized and treated in good time. In these cases the course can be lethal. But in our hemisphere this only happens because of the good medical care very rare (in less than 0.1% of cases).
