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Introduction
  • Defined as 3 or more ribs with segmental fractures
  • Epidemiology
    • bimodal distribution
      • younger patients involved in trauma
      • older patients with osteopenia
  • Mechanism
    • blunt forces
    • deceleration injuries
  • Associated Injuries
    • scapula fractures
    • clavicle fractures
    • hemo/pneumothorax
  • Prognosis
    • varies depending on underlying pulmonary injury or other concomitant injuries
Anatomy
  • Osteology
    • 12 ribs per side
      • the first seven pairs are connected with the sternum
      • the next three are each articulated with the lower border of the cartilage of the preceding rib
      • the last two have pointed extremities
    • can have an accessory clavicular rib
    • anterior ribs articulate with the sternum via the costal cartilage
  • Blood Supply
    • derived from intercostal vessels
Presentation
  • Symptoms
    • pain
    • respiratory difficulty
    • hemopneumothorax
  • Exam
    • paradoxical respiration  
      • area of injury "sinks in" with inspiration, and expands with expiration (opposite of normal chest wall mechanics)
    • chest wall deformity can be seen 
    • bony or soft-tissue crepitus is often noted
Imaging
  • Radiographs  
    • may be hard to distinguish non- or minimally-displaced rib fractures
    • may see associated hemothorax 
  • CT  
    • improved accuracy of diagnosis with CT (vs. radiographs)
Treatment
  • Nonoperative
    • observation
      • indications
        • no respiratory compromise
        • no flail chest segment (>3 consecutive segmentally fractured ribs)
      • techniques
        • pain control
          • systemic narcotics or local anesthetics
        • positive pressure ventilation
  • Operative
    • open reduction internal fixation
      • indications
        • displaced rib fractures associated with intractable pain
        • flail chest segment (3 or more consecutive ribs with segmental injuries)
        • rib fractures associated with failure to wean from a ventilator
        • open rib fractures
      • technique
        • approach
          • full thoracotomy approach
          • limited exposure approach
        • open reduction and internal fixation
          • plate and screw constructs  
          • intramedullary splinting
      • postop
        • early shoulder and periscapular range of motion
Complications
  • Intercostal neuralgia
  • Periscapular muscle weakness
  • Pneumonia
  • Restrictive type pulmonary function
 

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