Dr. Muhammad Younus - PowerPoint Presentation

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

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Rib Fractures

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Anatomy

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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)

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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 & side

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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)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 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 Rib

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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 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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ManubriumBroad, 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 JointA 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 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 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. COPDBarrel 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 LinesAnterior Chest

Midsternal line

Midclavicular line

Posterior Chest

Vertebral line – midspinalScapular line

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Lateral ChestAnterior Axillary linePosterior 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 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 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

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Bone Grafting

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