Younus MBBS MCPS FCPS Pulmonology Rib Fractures 4 Anatomy Anterior Thoracic Landmarks Suprasternal Notch U shaped depression Sternum breastbone 3 parts Manubrium Body ID: 390937
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Dr. Muhammad Younus MBBS, MCPS, FCPS (Pulmonology)Slide3
Rib FracturesSlide4
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AnatomySlide5
Anterior Thoracic LandmarksSuprasternal Notch – U shaped depression
Sternum – “breastbone” = 3 parts
Manubrium
Body
Xiphoid processAngle of Louis – manubriosternal angle continuous with the 2nd RibCostal angle- usually 900 or <. (increases when rib cage is chronically overinflated)Slide6Slide7
Posterior Thoracic LandmarksVertebra
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 Rib12th Rib = midway b/t spine & sideSlide8Slide9
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 breathingIntercostal spaces = (spaces between ribs)RibsSlide10
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.Slide11Slide12
Supernumerary (Extra) Rib present above the 1st ribArises 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 RibSlide13Slide14Slide15Slide16Slide17Slide18
Trauma is the most important cause of rib fracturesFirst 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 FracturesSlide19
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 FracturesSlide20
Tenth to twelfth
ribs
:
Associated with thoracic and lumber vertebral injuries
Injuries to spleen , kidneys adrenals , liver may occur. Rib FracturesSlide21
Pathological Rib Fractures: occurs spontaneously without trauma due to weakness of the bone by the underlying disease. - Metastasis
- Multiple myeloma
- Hyperparathyroidism Rib FracturesSlide22Slide23
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 Slide24
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 chestSlide25Slide26Slide27
Sternum
breastbone
Lies in anterior midline of thorax
Three parts:
ManubriumBodyXiphoid process Surface landmarksJugular notchSternal angle ( angle of Louis)Slide28
ManubriumBroad, upper part of the sternum
Quadrangular shape, wider superiorly and narrower inferiorly
Articulates with the clavicles and the first two ribs.Slide29
Manubrialsternal JointA ridge where the manubrium and the body of the sternum meet
Raised horizontal ridge located at the second rib jointSlide30
Xiphoid Process
Xiphoid means
“
sword-shaped”
May be bone or cartilageApex of thoracic arch“Pit” of stomach, where heartburn often occursSlide31
Blunt trauma to chestRarely may occur during CPRStress fractures weight lifters , golfersLong term steroids, severe kyphosis
Fractures usually occurs at body or manubrium
X-Rays Chest PA & Lateral Views , USG Chest
CT chest.
Sternal FracturesSlide32Slide33Slide34
Normal chestSlide35
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
excavatumSlide36Slide37
Pectus Excavatum (Funnel)Slide38
AP diameter is equal or more than transverse diameter. COPDBarrel Shape chestSlide39
Barrel ChestSlide40
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 Slide41
Pectus Carinatum (Pigeon)Slide42
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 Slide43
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 BiopsySlide44
Reference LinesAnterior Chest
Midsternal line
Midclavicular line
Posterior Chest
Vertebral line – midspinalScapular lineSlide45
Lateral ChestAnterior Axillary linePosterior Axillary line
Mid–axillary line Slide46Slide47Slide48Slide49
Surgical creation of an opening through the thoracic wall Types : - Anterior thoracotomy -
Posterolateral
thoracotomy
- Anterolateral thoracotomyPosterolateral thoracotomy is the most commonly used site. ThoracotomySlide50
Sternal splitting for the mediastinal operations For upper lobe lung tumoursCABAG
After surgery the halves of sternum are joined using wire sutures.
Median
sternotomySlide51Slide52Slide53Slide54
Atelectasis, the permanent collapse of lung tissueBenign (non-cancerous) tumors or cystsConfirmation of a diagnosis, such as for lung diseaseDiaphragm disordersDiseased or damaged blood vessels of the heart or lungs
Empyema, or infection in the chest cavity
Heart disease
Hemothorax
, 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 thoracotomySlide55
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 GraftingSlide56
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