Dr. Muhammad Younus MBBS, MCPS, FCPS (Pulmonology)

Rib Fractures

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Anatomy

Anterior Thoracic Landmarks Suprasternal Notch – U shaped

depression Sternum – “breastbone” = 3 parts

1. Manubrium2. Body3. Xiphoid process Angle of Louis – manubriosternal angle

continuous with the 2nd Rib Costal angle- usually 900 or <. (increases

when rib cage is chronically overinflated)

Posterior Thoracic Landmarks Vertebra Prominens – Flex head, feel most

prominent bony projection at base of neck = C7 next lower one is T1

Spinous Processes – spinal column- Scapula – symmetrical , lower tip at the 7 -

8th Rib 12th Rib = midway b/t spine & side

• 12 pairs of ribs• 7 true ribs• 5 false ribs (including 2 floating ribs)

• Head of rib articulates with vertebra• Ribs move as a unit to accommodate breathing• Intercostal spaces = (spaces between ribs)

Ribs

False and Floating Ribs

• All 12 pairs of ribs attach to the building blocks of the spine (vertebrae) in the back. The 12 pairs of ribs consist of:

• True ribs: The first seven ribs attach to the sternum (the breast bone) in the front and are known as true (or sternal) ribs.

• False ribs: The lower five ribs do not directly connect to the sternum and are known as false ribs.

• The upper three false ribs connect to the costal cartilages of the ribs just above them. The last two (#11 and 12) are false ribs. They have no ventral attachment (no anchor at all in front) and are called floating ribs.

Supernumerary (Extra) Rib present above the 1st rib

Arises from 7th cervical vertebra Present in 1 in 500 peoples Can cause thoracic outlet syndrome due to

compression on the brachial plexus and subclavian artery.

Cervical Rib

Trauma is the most important cause of rib fractures

First Rib : Rare , associated with cranial, maxillofacial ,cervical spinal injuries , multiple rib fractures and life threatening vascular injuries.

Second, Third and fourth : Associated with major vascular injuries and injury to brachial plexus.

Rib Fractures

Fifth to Ninth ribs : can be single or multiple. Multiple fractures can present as flail chest, which is present when paradoxical respiratory movement occurs in a segment of the chest wall.

This type of fracture requires at least 2 segmental fractures in each of 3 adjacent ribs, the costal cartilages, or the sternum

Rib Fractures

Tenth to twelfth ribs : Associated with thoracic and lumber vertebral injuries

Injuries to spleen , kidneys adrenals , liver may occur.

Rib Fractures

Pathological Rib Fractures: occurs spontaneously without trauma due to weakness of the bone by the underlying disease.

- Metastasis - Multiple myeloma - Hyperparathyroidism

Rib Fractures

◦ Pulmonary contusion (almost always) Airspace disease representing hemorrhage into the alveoli usually

subjacent to the point of impact◦ Pulmonary laceration

Lacerations in the lung may be blood-containing, air-containing, or both Frequently masked by the surrounding pulmonary contusion

◦ Pneumothorax (very common) Since the severity of the injury means a supine radiograph will be

performed, pneumothoraces may only be seen on chest CT◦ Hemothorax (common) ◦ Pneumomediastinum ◦ Subcutaneous emphysema ◦ Mediastinal hemorrhage◦ Aortic injuries

Complications

Flail chest is traditionally described as the paradoxical movement of a segment of chest wall caused by fractures of 3 or more ribs anteriorly and posteriorly within each rib.

Variations include posterior flail segments, anterior flail segments, and flail including the sternum with ribs on both sides of the thoracic cage fractured.

Severe blunt trauma

Flail chest

Sternum

breastbone Lies in anterior midline

of thorax Three parts:

◦ Manubrium◦ Body◦ Xiphoid process

Surface landmarks◦ Jugular notch◦ Sternal angle

( angle of Louis)

Manubrium

Broad, upper part of the sternum

Quadrangular shape, wider superiorly and narrower inferiorly

Articulates with the clavicles and the first two ribs.

Manubrialsternal Joint

A ridge where the manubrium and the body of the sternum meet

Raised horizontal ridge located at the second rib joint

Xiphoid Process

Xiphoid means “sword-shaped”

May be bone or cartilage

Apex of thoracic arch

“Pit” of stomach, where heartburn often occurs

Blunt trauma to chest Rarely may occur during CPR Stress fractures weight lifters , golfers Long term steroids, severe kyphosis

Fractures usually occurs at body or manubrium

X-Rays Chest PA & Lateral Views , USG Chest CT chest.

Sternal Fractures

Normal chest

Most common congenital deformity of anterior chest wall.

Also called funnel chest , sunken chest, cobblers chest.

Lower end of sternum is depressed alongwith costal cartilages.

Treatment is surgical repair.

Pectus excavatum

Pectus Excavatum (Funnel)

AP diameter is equal or more than transverse diameter.

COPD

Barrel Shape chest

Barrel Chest

Also called pigeon chest. Characterized by protrusion of sternum and

ribs Congenital, Obstructive airway disease,

Marfan syndrome, turner syndrome, Ehlers danlos syndrome.

Treatment is external braces or surgical.

Pectus Carinatum

Pectus Carinatum (Pigeon)

Very rare Sternal defects can be categorized into 4

types,: thoracic ectopia cordis cervical ectopia cordis thoracoabdominal ectopia cordis cleft sternum. Sternal foramina – perforation in sternal

body clinically insignificant. Perforation of xiphoid process in elderly.

Sternal defects

Often used for bone marrow needle biopsy because of its breadth and subcutaneous position

Commonly used for specimen for bone marrow transplant and for the detection of metastatic cancers and blood dyscrasias .

Sternal Biopsy

Reference Lines Anterior Chest

◦ Midsternal line◦ Midclavicular line

Posterior Chest◦ Vertebral line – midspinal◦ Scapular line

Lateral Chest◦ Anterior Axillary line◦ Posterior Axillary line◦ Mid–axillary line

Surgical creation of an opening through the thoracic wall

Types : - Anterior thoracotomy - Posterolateral thoracotomy - Anterolateral thoracotomy

Posterolateral thoracotomy is the most commonly used site.

Thoracotomy

Sternal splitting for the mediastinal operations

For upper lobe lung tumours CABAG

After surgery the halves of sternum are joined using wire sutures.

Median sternotomy

Atelectasis, the permanent collapse of lung tissue Benign (non-cancerous) tumors or cysts Confirmation of a diagnosis, such as for lung disease Diaphragm disorders Diseased or damaged blood vessels of the heart or lungs Empyema, or infection in the chest cavity Heart disease Hemothorax, or blood in the lungs Lung damage caused by emphysema or bronchietasis Pleurodesis, a procedure to treat a buildup of fluid in the chest cavity Pneumothorax, or injuries that cause the collapse of lung tissue Pulmonary embolism, or a blood clot in the lungs or pulmonary artery Severe and very specific types of chest injury or trauma, such as

certain types of stabbings or gunshot wounds  Some types of cancer including lung cancer Trachea (windpipe) or esophageal (swallowing tube) conditions

Indications of thoracotomy

A bone graft is surgery to place new bone or bone substitutes into spaces around a broken bone or bone defects.

If the transplanted bone comes from another person, it is called an allograft.

 If the transplanted bone comes from another part of your own body, it is called an autograft. 

Bone Grafting

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