Dr. Asif Hanif Assistant Professor - PowerPoint Presentation

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Dr.

Asif

Hanif

Assistant Professor

MBBS, FCPS,

DTCD(Pulmonology),

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Rib Fractures

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Anatomy

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Anterior Thoracic Landmarks

Suprasternal Notch – U shaped depression

Sternum – “breastbone” = 3 parts

ManubriumBodyXiphoid processAngle of Louis – manubriosternal angle continuous with the 2nd RibCostal angle- usually 900 or <. (increases when rib cage is chronically overinflated)

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Posterior Thoracic Landmarks

Vertebra

Prominens

– Flex head, feel most prominent bony projection at base of neck = C7 next lower one is T1Spinous Processes – spinal column- Scapula – symmetrical , lower tip at the 7 -8th Rib12th Rib = midway b/t spine & side

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12 pairs of ribs

7 true ribs

5 false ribs (including 2 floating ribs)

Head of rib articulates with vertebraRibs move as a unit to accommodate breathingIntercostal spaces = (spaces between ribs)Ribs

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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.

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Supernumerary (Extra) Rib present above the 1

st

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

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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

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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

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Tenth to

twelfth

ribs

: Associated with thoracic and lumber vertebral injuries Injuries to spleen , kidneys adrenals , liver may occur. Rib Fractures

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Pathological Rib Fractures:

occurs spontaneously without trauma due to weakness of the bone by the underlying disease.

- Metastasis - Multiple myeloma - Hyperparathyroidism Rib Fractures

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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 bothFrequently masked by the surrounding pulmonary contusionPneumothorax (very common) Since the severity of the injury means a supine radiograph will be performed, pneumothoraces may only be seen on chest CTHemothorax (common)

Pneumomediastinum Subcutaneous emphysema Mediastinal

hemorrhage

Aortic injuries

Complications

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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

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Sternum

breastbone

Lies in anterior midline of thorax

Three parts:ManubriumBodyXiphoid process Surface landmarksJugular notchSternal angle ( angle of Louis)

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Manubrium

Broad, upper part of the sternum

Quadrangular shape, wider superiorly and narrower inferiorly

Articulates with the clavicles and the first two ribs.

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Manubrialsternal

Joint

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

Raised horizontal ridge located at the second rib joint

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Xiphoid Process

Xiphoid means

“

sword-shaped”May be bone or cartilageApex of thoracic arch“Pit” of stomach, where heartburn often occurs

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Blunt trauma to chest

Rarely may occur during CPR

Stress fractures weight lifters , golfers

Long term steroids, severe kyphosisFractures usually occurs at body or manubriumX-Rays Chest PA & Lateral Views , USG Chest CT chest.Sternal Fractures

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Normal chest

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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

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Pectus Excavatum (Funnel)

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AP diameter is equal or more than transverse diameter.

COPD

Barrel Shape chest

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Barrel Chest

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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

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Pectus Carinatum (Pigeon)

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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

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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

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Reference Lines

Anterior Chest

Midsternal line

Midclavicular linePosterior ChestVertebral line – midspinalScapular line

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Lateral Chest

Anterior Axillary line

Posterior Axillary line

Mid–axillary line

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Surgical creation of an opening through the thoracic wall

Types :

- Anterior thoracotomy - Posterolateral thoracotomy - Anterolateral thoracotomyPosterolateral thoracotomy is the most commonly used site. Thoracotomy

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Sternal splitting for the

mediastinal

operations

For upper lobe lung tumoursCABAG After surgery the halves of sternum are joined using wire sutures.Median sternotomy

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Atelectasis, the permanent collapse of lung tissue

Benign (non-cancerous) tumors or cysts

Confirmation of a diagnosis, such as for lung disease

Diaphragm disordersDiseased or damaged blood vessels of the heart or lungsEmpyema, or infection in the chest cavityHeart diseaseHemothorax, or blood in the lungsLung damage caused by emphysema or bronchietasisPleurodesis, a procedure to treat a buildup of fluid in the chest cavityPneumothorax, or injuries that cause the collapse of lung tissuePulmonary embolism, or a blood clot in the lungs or pulmonary arterySevere and very specific types of chest injury or trauma, such as certain types of stabbings or gunshot wounds Some types of cancer including lung cancerTrachea (windpipe) or esophageal (swallowing tube) conditionsIndications of thoracotomy

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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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