Rib fractures

Introduction to rib fracture There are 12 pairs of ribs, which are equally divided on both sides of the chest. The front is connected with the sternum and the posterior thoracic vertebrae to form a complete foot. In chest injuries, rib fractures are the most common, whether they are closed or open injuries, accounting for approximately 90% of thoracic fractures. Rib fractures caused by different forms of external violence can have different characteristics: rib fractures caused by direct violence on the localized parts of the chest, and the ends of the fractures are displaced inward, which can pierce the intercostal vessels, pleura and lungs. The production of hemothorax or (and) pneumothorax, indirect violence, such as the chest is squeezed before and after, the fracture is mostly in the middle of the rib, the broken end is displaced outward, stabbing the soft tissue of the chest wall, resulting in chest wall hematoma. The rib fracture caused by gunshot wound or shrapnel injury is often a comminuted fracture. In children, the ribs are elastic and not easy to break. In adults, especially the elderly, the ribs are weakened and easy to fracture. basic knowledge The proportion of illness: 0.07% Susceptible people: no specific population Mode of infection: non-infectious Complications: acute heart failure, atelectasis

Cause of rib fracture

(1) Causes of the disease

In children and adolescence, the rib itself is elastic, not easy to break, sometimes there is damage to the internal organs without rib fractures, the elderly ribs are decalcified, fragile, sometimes due to minor injuries or even coughing or sneezing, can also cause fractures, ribs Fractures are generally caused by external violence. When direct violence is applied to the chest, rib fractures often occur in the affected area, the fracture ends are broken inward, and the internal organs cause damage.

When indirect violence acts on the chest, such as the violent compression of the chest, the rib fracture occurs at a location other than the point of violence. The fracture end is outward, which easily damages the soft tissue of the chest wall and produces a chest hematoma.

Open fractures are more common in direct damage to firearms or sharps. In addition, fractures occur on the basis of pathological changes in the ribs such as osteoporosis, osteomalacia or primary and metastatic rib tumors, called pathological rib fractures.

(two) pathogenesis

Rib fracture often occurs in the 4th to 10th ribs, the first to third ribs are short, and there are scapula, clavicle protection, not easy to fracture, the 11th to 12th ribs are floating ribs, the mobility is large, the fracture is rare, but if the first ~ 3 ribs or 11 ~ 12 rib fractures, often external forces are very strong, should pay close attention to the presence of intrathoracic or intra-abdominal organ damage, due to different injury violence, can produce single or multiple rib fractures, each The ribs can be broken in one or more places: a single fracture, such as no intrathoracic organ injury, is not serious, but there are two adjacent ribs at the same time with more than two fractures, which can cause the chest to produce an abnormal respiratory movement. Influencing respiratory and circulatory function, costal cartilage fracture often occurs in the costal cartilage and rib or junction with the sternum, and easy to dislocation, the site of sternal fracture often occurs at the junction of the sternum body or the shank, due to easy intrathoracic organ damage, The mortality rate is 25% to 45%.

Rib fracture prevention

1, dietary taboos

(1) Avoid eating more meat bones: If a large amount of meat bones are taken after fracture, it will promote the increase of inorganic components in the bone, leading to the imbalance of the organic matter in the bone, which will hinder the early healing of the fracture.

(2) avoid eclipse: fracture patients are often accompanied by local edema, congestion, hemorrhage, muscle tissue damage, etc., the body itself is resistant to these repairs, and the body repair tissue phlegm swelling mainly depends on a variety of nutrients.

(3) Avoid eating foods that are not easy to digest: patients with fractures are restricted in activities due to fixed plaster or splint, plus swelling and pain in the wounds, mental anxiety, and often loss of appetite. Therefore, food should be nutritious and easy to digest. Eat more fruits and vegetables.

(4) avoid drinking less water: patients with fractures in bed are very inconvenient to move, so drink less water to reduce the number of urination, so that patients with less activity, weakened bowel movements, easy to cause constipation, so patients with bed fractures want to drink water drink.

(5) avoid excessive consumption of white sugar: a large amount of white sugar will cause rapid metabolism of glucose, alkaline calcium, magnesium, sodium and other ions will participate in neutralization to prevent blood from appearing acidic, so calcium consumption will not Conducive to the rehabilitation of patients with fractures.

2, should eat more vegetables, protein and vitamin-rich diet, can prevent the occurrence and development of osteoporosis, early diet should be light, in order to facilitate the swelling of the phlegm; later should be partial taste, choose the right diet to adjust the liver Kidney is good for fracture healing and functional recovery.

3, the disease often occurs in the middle, the elderly, rarely seen in children.

4, when treatment, the patient should be placed in a semi-recumbent position, rest, oral painkillers, fractures, wounds and painkillers, blood circulation and cold cream, etc., if the condition is serious, should go to the hospital for treatment, such as pneumothorax, blood chest is taken accordingly Treatment measures.

Rib fracture complications Complications acute heart failure atelectasis

1, acute heart failure

Patients with rib fracture complicated with acute heart failure are mostly multiple rib fractures. Patients with this disease should closely observe vital signs and disease changes in the early stage to prevent cardiopulmonary failure. Once early symptoms appear, they should be immediately rescued to prevent cardiac arrest and heartbeat. Once the chest compression is not suitable, the extra-thoracic heart compression can deepen the rib fracture and deepen the damage to the heart and lung, affecting the rescue effect and endangering the patient's life. Immediately open the chest, chest compression, chest heart Pressing the heart to discharge blood is higher than chest compression, the effect is better. Patients with multiple rib fractures should be immediately treated with chest rib fixation or other methods to fix the chest wall to prevent abnormal breathing and cause cardiopulmonary damage. Bad consequences, keeping the disease in its infancy.

2, atelectasis

The cause of atelectasis accounted for 59.5 % of the tumors, the inflammation accounted for 32.7 %, the tuberculosis accounted for 4 % of the 3rd place, and the left lateral multiple rib fracture caused the right atelectasis. Caused by infection, the reasons are as follows:

1 From the anatomical features, the right bronchus is shorter and thicker, and the angle formed by the longitudinal axis of the main bronchus is smaller, and the sputum easily falls into the right lung.

2 from the position analysis, because after admission, it is often emphasized that the patient needs a lateral position, on the one hand, the respiratory secretions flow into the right lung by gravity, and on the other hand, the long-term right lateral position affects the right respiratory muscle. And thoracic movement, resulting in reduced lung capacity and decreased tidal volume.

3 If the patient's poor medical behavior will also cause the patient to have atelectasis, due to deep breathing, local pain will increase when coughing, if the patient does not cooperate with deep breathing and effective cough, do not dare to change the position and cause secretions to block the respiratory tract.

4 more common in patients who did not have a chest wall fixation in time.

Rib fractures can be combined with intrathoracic organ damage.

Rib fracture symptoms Common symptoms Inability to breathe chest pain edema and even thoracic conduction abdominal pain multiple rib fracture shock hemot

1, symptoms

Occasionally, due to severe coughing or sneezing, the chest muscles suddenly contract and cause rib fractures, which are called spontaneous rib fractures, which occur in the 6th to 9th ribs of the axilla. When the rib itself has lesions, such as primary tumors. Or metastases, etc., rib fractures may occur under very light external forces or without external force, called pathological rib fractures.

Rib fractures occur in the 4th to 7th ribs; the 1st to 3rd ribs have clavicle, the scapula and shoulder belt muscles are protected from injury; the 8th to 10th ribs are gradually shortened and connected to the cartilage rib arch. Buffering, the chance of fracture is reduced; the 11th and 12th ribs are floating ribs, with a high degree of mobility and very few fractures, but when the violence is strong, these ribs may have fractures.

Only one rib fracture is called a single rib fracture, two or more rib fractures are called multiple rib fractures, rib fractures can occur simultaneously on both sides of the chest, and only one fracture per rib is called a single fracture. Two or more fractures are called double or multiple fractures, multiple multiple rib fractures or multiple rib fractures with multiple rib cartilage osteophytes or bilateral multiple costal cartilage fractures or osteophyte detachment The chest wall is softened, called the chest wall floating injury, also known as the chest.

Local pain is the most obvious symptom of rib fracture, and it is aggravated by cough, deep breathing or body rotation. Sometimes the patient can hear or feel the bone friction at the rib fracture at the same time, pain and chest stability. Sexually disrupted, limited respiratory motility, shallow breathing and reduced alveolar ventilation, patients do not dare to cough, retention, resulting in lower respiratory secretion obstruction, lung wet or atelectasis, which in the elderly or weak patients or Patients with existing lung diseases should pay special attention to it. In the chest, when inhaling, the negative pressure in the chest increases, and the softened part of the chest wall is inwardly depressed. When exhaling, the pressure in the chest cavity increases, and the damaged chest wall floats. Contrary to the movement of other chest walls, it is called abnormal breathing exercise. Abnormal breathing exercise can make the chest pressure imbalance on both sides. The mediastinum moves back and forth with the breathing, which is called mediastinal swing, which affects blood return and causes circulation function. Disorders are one of the important factors leading to and aggravating shock. Chest pain and thoracic stability damage are more serious when the chest is removed, and abnormal breathing exercises make the respiratory movement more difficult. Restricted movement, cough, weakness, decreased vital capacity and functional residual capacity (FRC), decreased lung compliance and tidal volume, often accompanied by severe dyspnea and hypoxemia. In the past, it was thought that some gas was accompanied by Inhalation and exhalation flow back and forth between the healthy side and the injured side of the lungs, and cannot be exchanged with the atmosphere. It is called residual convection or oscillating gas, which is the main cause of respiratory dysfunction. Exist, and even the lung contusion often associated with chest pain can cause alveolar and interstitial hemorrhage, edema, alveolar rupture and atelectasis, is an important cause of respiratory dysfunction.

A rib fracture without a combined injury is called a simple rib fracture. In addition to the pleural and lung injury and the hemothorax or (and) pneumothorax caused by it, it is often combined with other chest injuries or injuries outside the chest. It should be noted that the first or second rib fracture often combined with clavicle or scapular fracture, and may be associated with intrathoracic organ and large vessel injury, bronchial or tracheal rupture, or cardiac contusion, often combined with craniocerebral injury; lower thoracic rib fracture may be combined with abdomen Internal organ injury, especially liver, spleen and kidney rupture, should also pay attention to the spinal and pelvic fractures, but when the ribs below the 7th rib fracture, due to stimulation of the intercostal nerve at the fracture, resulting in conductive abdominal pain, should pay attention to It is differentiated from hereditary abdominal pain caused by abdominal organ injury.

2, auxiliary inspection

Most of the X-ray films can show rib fractures. However, for costal cartilage fractures, "wasting fractures", fractures without dislocations, or middle rib fractures on the chest radiograph because the ribs on both sides overlap each other, are not easy to find, should be combined with clinical Performance to judge to avoid missed diagnosis.

If there is a history of chest trauma, local pain and tenderness in the chest wall, chest compression test is positive, chest fracture may be thought of, can be diagnosed by X-ray examination, if the tender point can touch the friction sound, the diagnosis can be established, if the chest wall appears abnormal breathing movement , indicating that there are multiple rib fractures.

Rib fracture examination

Patients with rib fractures can be examined using the following methods:

(1) X-ray film is the first choice for the diagnosis of rib fractures. It is mainly because of its convenient examination. It is convenient to locate the fracture, and the cost is low. The fracture site can be observed, and the fracture line or the broken end of the rib fracture can also be seen. You can understand the damage and complications of the internal organs of the chest, but you should pay attention to the fractures without displacement, the fractures in the sacral area or the fractures at the costal cartilage. X-ray photographs are not easy to show, and early diagnosis is easy to miss. 3-6 after injury. Weekly re-extraction of X-ray chest photos, it can be shown that after the fracture, there is a shadow of the epiphysis, and the sternal fracture can clearly show the fracture image in the lateral scapula.

(2) Due to the increased window technology, the CR piece has a significant improvement in the display of rib fractures compared with the traditional X-ray film. Most rib fractures can be found, but the ribs and ribs of the underarm are due to overlapping structures. CR films in rib fractures are still difficult to show. For some fractures and fractures with no dislocations, there are often missed diagnosis, especially for fractured fractures. For some fractures with incomplete osteophytes, CR is also diagnosed. Defects, the diagnosis is not clear.

(3) Spiral CT and reconstructed images show that rib fractures are more sensitive than CR slices, and the accuracy is high. There are statistical differences between them. Compared with some literature reports, spiral CT can be used for rapid continuous scanning and volumetric data acquisition. Multi-plane post-processing image recombination can clearly and visually display lesions. The patient's coordination requirements are lower than CR radiographs, and the complications of chest injury are clearer and more comprehensive than CR films.

(4) Combined with CT transverse position and reconstructed images, the position of the fracture line can be more accurately observed. For the submental fractures that are easily missed by CR, rib arch fracture, anterior rib fracture and fracture without dislocation, the fracture fracture has obvious advantages. It is considered to be the most accurate method for diagnosing rib fractures. CR films with fissure fractures can only suggest suspicious fractures, and are easy to be diagnosed. Thin-layer scanning and reconstruction of spiral CT are suspicious to solve the diagnosis problem. For costal cartilage injury, reconstruction after spiral CT is passed. The image can show the shape and internal structure of the costal cartilage, which can give a more accurate diagnosis. For the CR piece that fails to show the fracture, and the clinically highly suspected fracture, especially the incomplete fracture of the armpit, it is recommended to perform spiral CT examination. Can avoid missed diagnosis, there is a need to clearly diagnose the patient, regardless of whether the CR is found or not, spiral CT examination should be considered.

Diagnosis and diagnosis of rib fracture

diagnosis

The diagnosis of rib fractures is based on the history of injury, clinical presentation and chest X-ray examination.

Differential diagnosis

In the case of rib fracture, non-displacement fracture is the main cause of misdiagnosis. The structure of the rib is relatively thin, lack of contrast, and the fracture line without displacement is relatively small and easy to be misdiagnosed. It is easy to ignore the existence of rib fracture when accompanied by other serious injuries. In the case of pulmonary contusion combined with liquid pneumothorax, heart injury, clavicular fracture, scapular fracture and tuberculous pleurisy, pleural hypertrophy is easy to cause misdiagnosis, so it should be carefully identified clinically.

Clinical rib fractures also need to be differentiated from intrapulmonary nodular lesions:

In the healing process, rib fractures form an expansive osteophytes at the 2nd end of the fracture, similar to nodular pulmonary lesions, especially in the elderly. It is easily misdiagnosed as pulmonary nodular lesions without a history of obvious trauma, especially when When the rib is transversely fractured, the epiphysis is formed in a nodular shape, because the fracture joint is up and down, and the fracture fracture is thick and thick, forming a semi-circular shape. On the orthotopic chest radiograph, the upper and lower edges of the rib are semi-circular, forming a circular nodule. Shadow, very similar to the pulmonary nodular lesions overlap with the ribs, because the ribs are fractured on the lateral side, so the lateral side is attached to the lateral chest wall. Under the lung field, it is difficult to distinguish between true and false, because the formation of the epiphysis is coherent, so its Edge smoothing, regular, no lobulated depression and pleural indentation signs, so in the case of difficult to diagnose, CT examination should be performed, CT examination has high resolution, and the trabecular bone is clearly visible through the fracture.

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