Multiple rib fractures

Introduction 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. Only one fracture per rib is called a single fracture, and two or more fractures are called two or more fractures. Multiple multiple rib fractures or multiple rib fractures with multiple rib cartilage osteophytes or bilateral multiple costal cartilage fractures or osteophyte detachment, resulting in chest wall softening, known as chest wall floating injury, also known as sputum chest.

Cause

(1) Causes of the disease

In children and adolescence, the ribs themselves are flexible and not easy to break. Sometimes there is damage to the internal organs without rib fractures. The ribs of the elderly are decalcified and fragile, and sometimes they can cause fractures due to minor injuries or even coughing or sneezing. Rib fractures are generally caused by external violence. When direct violence occurs on the chest, rib fractures often occur in the affected area, the fracture end is 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.

Radioactive fractures are more common in direct damage to firearms or sharps. In addition, when the rib has pathological changes such as osteoporosis, osteomalacia or primary and metastatic rib tumors, a fracture is called a pathological rib fracture.

(two) pathogenesis

Rib fractures often occur in the 4th to 10th ribs. The first to third ribs are short, and there are shoulder blades and clavicle protection, which are not easy to fracture. The 11th to 12th ribs are floating ribs, and the mobility is large, and the fracture is rare. However, if the first to third ribs or the 11th to 12th rib fractures are caused, the external force is often severely hit, and attention should be paid to the presence or absence of intrathoracic or intra-abdominal organ damage. Due to different injury and violence, single or multiple rib fractures can be produced, and each rib can be broken at one or more places: a single fracture, such as no intrathoracic organ damage, is not serious. However, there are two or more ribs that are adjacent to each other at the same time, which can cause the chest to produce abnormal breathing, which seriously affects the breathing and circulation functions. Costal cartilage fractures often occur in the costal cartilage and ribs or junctions with the sternum and are prone to dislocation. The site of sternal fracture often occurs at the junction of the sternum or the stalk, and the mortality rate is 25% to 45% due to the easy involvement of intrathoracic organ injury.

an examination

Related inspection

Thoracic wall examination of bone and joint soft tissue CT examination chest test

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

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 armpit. When the rib itself has a lesion, such as a primary tumor or a metastatic tumor, a rib fracture may occur under a very light external force or no external force, which is called a pathological rib fracture.

Rib fractures occur mostly in the 4th to 7th ribs. The 1st to 3rd ribs are protected by the clavicle, scapula and shoulder muscles, and 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, the mobility is large, and there are few fractures. However, 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. Only one fracture per rib is called a single fracture, and two or more fractures are called two or more fractures. Multiple multiple rib fractures or multiple rib fractures with multiple rib cartilage osteophytes or bilateral multiple costal cartilage fractures or osteophyte detachment, resulting in chest wall softening, known as chest wall floating injury, also known as sputum 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 rib fracture at the same time. Pain and thoracic stability are compromised, which limits respiratory mobility, shallow breathing, and reduced alveolar ventilation. Patients do not dare to cough and stay, causing obstruction of lower respiratory tract secretions, lung wetness, or atelectasis. This should be especially valued in patients with old and weak patients or patients with existing lung diseases.

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 is increased, and the damaged chest wall is floating, which is opposite to the movement of other chest walls, called "abnormal breathing." motion". Abnormal respiratory movement can make the chest pressure imbalance on both sides, the mediastinum moves back and forth with the breathing, called "mediastinal swing", affecting blood reflux, causing circulatory dysfunction, which is one of the important factors leading to and aggravating shock. Chest pain and thoracic stability are more severe when the chest is broken. Abnormal breathing exercises restrict respiratory movement, cough, weakness, decreased vital capacity and functional residual capacity (FRC), decreased lung compliance and tidal volume, often accompanied by severe breathing. Difficulties and hypoxemia.

In the past, it was thought that some of the gas in the chest was flowing back and forth between the healthy side and the injured side lung as it inhaled and exhaled. It could not be exchanged with the atmosphere. It was called residual convection or oscillating gas, which caused respiratory function. The main cause of the obstacle. At present, it is believed that the oscillating gas does not exist, and the pulmonary contusion often accompanied by the chest can cause alveolar and interstitial hemorrhage, edema, alveolar rupture and atelectasis, which are important causes of respiratory dysfunction.

A rib fracture without a combined injury is called a simple rib fracture. In addition to pleural and lung injury and the resulting hemothorax or (and) pneumothorax, often combined with other chest damage or damage outside the chest, especially in the diagnosis. 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 associated with intra-abdominal organ injury In particular, the liver, spleen and kidney rupture, should also pay attention to the spinal and pelvic fractures. However, when the ribs below the 7th rib are fractured, due to stimulation of the intercostal nerve at the fracture, conductive abdominal pain occurs, and attention should be paid to the identification of abdominal pain caused by abdominal organ injury.

2, auxiliary inspection

X-ray chest radiographs can mostly show rib fractures, but for costal cartilage fractures, "willow branch fractures", fractures without dislocations, or middle rib fractures on the chest radiograph because the ribs on both sides overlap each other, it is 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, and a positive chest compression test, a thoracic fracture may be considered, and X-ray examination may confirm the diagnosis. If the tenderness is touched, the diagnosis can be established. If there is abnormal breathing movement on the chest wall, there are multiple rib fractures.

Differential diagnosis

In the case of rib fracture, non-displacement fracture is the main cause of misdiagnosis. The structure of the ribs is relatively thin, lacking contrast, and the fracture line without displacement is relatively subtle and easy to be misdiagnosed. When accompanied by other serious injuries, it is easy to ignore the existence of rib fractures, such as pulmonary contusion combined with liquid pneumothorax, heart injury, clavicular fracture, scapular fracture and tuberculous pleurisy pleural hypertrophy is easy to cause misdiagnosis. Therefore, the clinical should be carefully identified.

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

During 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, which are easily misdiagnosed as pulmonary nodular lesions without a history of obvious trauma. Especially when the ribs are transversely fractured, the formation of the epiphysis is nodular, because the fracture is up and down, and the fracture is thick and thick, forming a semi-circular shape. On the chest radiograph, the upper and lower edges of the ribs are semi-circular, forming a circular nodule. Much like 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 background of the lung field, it is difficult to distinguish between true and false. Because of the coherence of the formation of the epiphysis, the edge is smooth, regular, no lobulated depression and signs of pleural depression. Therefore, in the case of difficult diagnosis, CT examination should be performed. The CT examination has high resolution and the trabecular bone is clearly visible through the fracture.

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