I. What is a multiple rib fracture?
Three or more rib fractures are called multiple fractures. Rib fractures account for about 61% to 90% of chest injuries. In children, the ribs are elastic and not easy to break, while in adults, especially the elderly, the ribs are less elastic and easy to fracture.
What are the causes of rib fractures?
Rib fracture lesions caused by different forms of external violence can have different characteristics: rib fractures caused by direct violence acting on a restricted part of the chest, with the severed end displaced inward, can puncture the intercostal vessels, pleura and lungs, producing a hemothorax or (and) pneumothorax. In indirect violence, such as when the chest is crushed anteriorly and posteriorly, the fracture is mostly in the middle part of the rib, and the broken end is displaced outward, piercing the soft tissue of the chest wall and producing a chest wall hematoma. Rib fractures caused by gunshot or shrapnel injuries are often comminuted fractures.
What are the symptoms of rib fracture?
Local pain is the most obvious symptom of rib fracture, and it is aggravated by coughing, deep breathing or body rotation, etc. Sometimes the patient can hear or feel the “thumping” bone friction at the rib fracture. The pain and the disruption of the thoracic stability can lead to restricted respiratory dynamics, shallow and rapid breathing and reduced alveolar ventilation, and the patient is afraid to cough and retain sputum, which can lead to obstruction of lower airway secretions, pulmonary wetting or pulmonary atelectasis. This is especially important in elderly and frail patients or those with pre-existing lung disorders.
Multiple rib fractures can result in “paradoxical respiratory movements”, which is an important factor in causing and aggravating shock. Fractures of the 1st or 2nd rib are often combined with fractures of the clavicle or scapula, and may be combined with injuries to the thoracic organs and great vessels, bronchial or tracheal ruptures, or heart contusions, and often with cranial injuries; fractures of the ribs in the lower thorax may be combined with injuries to the abdominal organs, especially ruptures of the liver, spleen, and kidneys, and with fractures of the spine and pelvis. However, when the ribs below the 7th rib are fractured, conductive abdominal pain can be produced due to the stimulation of the intercostal nerve at the fracture site.
IV. What tests should be done?
The diagnosis of rib fracture is mainly based on the history of injury, clinical manifestations and X-ray chest examination. Most of the X-ray chest films can show rib fractures, but for rib cartilage fractures, “green branch fractures”, fractures without dislocation, or mid-rib fractures are not easily detected on chest films because the ribs on both sides overlap each other, so CT three-dimensional imaging is required.
V. What are the consequences of multiple rib fractures?
In the early stages, rib fractures are often associated with other thoracic injuries (e.g., diaphragm) or injuries outside the chest (e.g., liver/spleen), in addition to pleural and pulmonary injuries and intercostal vascular nerve injuries and the resulting hemothorax or (and) pneumothorax.
Recently, pain and disruption of thoracic stability can lead to restricted respiratory mobility, shallow and rapid breathing and reduced alveolar ventilation, with the patient afraid to cough and sputum retention, which can lead to obstruction of lower airway secretions, pulmonary wetting or atelectasis/pulmonary infection, and respiratory failure (ARDS). This is especially important in elderly and frail patients or those with pre-existing pulmonary disorders.
In the later stage, the healing of the rib deformity causes long-term compression of the intercostal nerve, and patients suffer from long-term intercostal neuralgia, which seriously affects the quality of life and has poor treatment outcome. Thoracic deformity, lung volume reduction, partial loss of lung capacity, affecting work life.
VI. What treatment methods are available?
The principles of treatment for simple nondisplaced rib fracture are pain relief, fixation and prevention of lung infection. Pain relievers can be administered orally or intramuscularly if necessary. Intercostal nerve block or painful point closure has good temporary pain relief and improves respiratory and effective cough function. Semi-annular tape fixation is effective in stabilizing the fracture and relieving pain. However, because its pain relief is not ideal, restricts breathing and has complications such as skin allergy, it is not advocated for inpatients except when considered for transfer of casualties, and better results are obtained with the application of a chest strap or elastic chest band.
Surgical fixation is preferred for multiple displacements combined with hemothorax. The surgical options are: incisional fracture reduction and internal fixation, thoracoscopic-assisted rib fracture reduction and internal fixation. The internal fixation methods are: internal fixation with a Kirschner pin, internal fixation with a wire, internal fixation with a Juddy plate, and internal fixation with an absorbable nail. Suspension external fixation has been eliminated due to poor results, patient pain and care difficulties.
VII. How to prevent complications caused by fracture?
Prevention of pulmonary complications mainly lies in encouraging the patient to cough, sit up early and assist in sputum removal, and perform endotracheal aspiration by fibrinoscopy if necessary. Give antimicrobials and expectorants in appropriate amounts. Chinese medicine is used to activate blood circulation and relieve pain, and to prevent the occurrence of pulmonary edema or acute lung injury and ARDS.
What are the characteristics of our hospital in treating multiple rib fractures?
Thoracoscopic-assisted absorbable rib nail fracture internal fixation-using thoracoscopic accurate positioning, rib fracture reset and embedded absorbable internal fixation nail, anatomical reset, expansion and shaping of the intramedullary nail within a short period of time, the fracture end can no longer be displaced, the intramedullary nail induces bone scab growth, no need for internal fixation removal, the operation is less traumatic, low risk, short time, and few postoperative thoracic and pulmonary complications, which is currently the The most perfect treatment method.
Internal fixation with an incisional repositioning memory alloy fixator – the application of the annular rib fixator enables anatomical alignment of fractures, especially comminuted fractures, strong internal fixation, and the patient can get out of bed 5 days after surgery, short hospital stay, reduced nursing workload, and fewer complications. The disadvantage is that it requires a second hospitalization to remove the internal fixation.
Medical glue fracture end injection internal fixation – the application of medical glue positioning injection technology, early stabilization of the fracture end, reduce the patient’s pain. In combination with external fixation, patients with fractures without significant displacement can be treated in a timely manner.