This site or third-party tools used by this make use of cookies necessary for the operation and useful for the purposes described in the cookie policy. By clicking on "I accept" you consent to the use of cookies.

Chest trauma, rib and sternal fractures

  1. Gastroepato
  2. Pneumology
  3. Chest trauma, rib and sternal fractures
  4. Chest trauma
  5. Pneumothorax
  6. Tracheal pathology
  7. Dyspnea
  8. Patient with a dry, productive cough

notes by dr Claudio Italiano

vedi anche Chest trauma 

The chest trauma

Chest traumas are responsible about 20 to 50% of deaths due to traumatic injuries. The "unstable" chest injury is common in at least 31% of 50,000 traumatized patients. The unstable chest or chest  flail segment is defined as the fracture of 3-4 ribs or more on a longitudinal segment, a condition that generates a phenomenon in which the fractured part does not follow the thoracic movements of expansion in inhalation and collapse in exhalation, but it moves on its own in exactly the opposite way, causing alteration of the respiratory dynamics of the rib cage, which becomes unstable, loses continuity and is perturbed in the movements of the breath. In fact, the rib cage, in addition to protecting the internal organs, provides to maintain a condition of ventilation, just like a bellows. The causes of rib fracture generally depend on traffic accidents, indirect trauma, sudden acceleration-deceleration, or more often on direct trauma, with the application of a force that compresses and exceeds the resistance of the costal arch, e.g. when the steering hits the chest.
This leads to complications ranging from retention of secretions and collapse of the part of the lung parenchyma involved in the process and adjacent to the flail, up to the pneumothorax or hemothorax, with reduction of respiratory mechanics and ventilatory mechanics and therefore of the functional residual capacity.

Rib fractures

The parietal contusion is the most common lesion of the thorax. Although without bone lesions, it can cause pulmonary bruises, especially in children and young people whose rib cage is very elastic. Contusions can be very painful and limit respiratory excursions. The decreased compliance (pain, hypomobility) of the haemorrhaging site of fractures or even of costal contusions, especially in the elderly subject or with chronic pulmonary disease, can lead to parenchymal complications, such as atelectasis and pneumonia. This can decompensate a situation of pre-existing respiratory failure, so it is essential to control pain and help the bronchial patency (puff of cortisone, respiratory gymnastics, fluidizing). Costal fractures affect the lower and middle most frequently. Rare is the isolated fracture of the I coast, particularly robust and protected by other structures such as clavicle and scapula. The associated fractures of the I and II ribs can be accompanied by vascular lesions, especially in the artery and axillary vein or subclavian vein. These should be suspected if there is a decrease or disappearance of the ipsilateral radial pulse, if a hemothorax or extra-pleural hematoma develops and there is a brachial plexus injury.

An echo-doppler and, better, urgent arteriography are indicated. In the elderly, even negligible traumas can cause fractures due to stiffness and osteoporosis, but also hyperparathyroidism and bone metastases should be excluded. Bone stumps can tear the lung parenchyma and cause pneumothorax with or without hemothorax. These can manifest themselves clinically or radiologically even after hours or days from the trauma. Hemothorax is usually caused by the tearing of an intercostal artery, rather than by direct lung trauma. The lesions of at least two points of the same coast, which occur in two or more adjacent ribs, give rise to a costal flail (see below). The suspicion of rib fracture arises when a pleural irritation pain, an ecchymosis and / or a hematoma, limited subcutaneous emphysema, a notable tension of the soft tissues above and, above all, the palpatory sign of the "throat" is present at the site of the trauma. "due to the rubbing of the bone abutments. Differential diagnosis with a strong contusion or incomplete fractures (infractions, "green wood"), even radiologically, is not always easy. The treatment is generally only antalgic and, occasionally, especially in the elderly, antibiotic to prevent pneumonia outbreaks (poor motility and reduced expectoration capacity). In cases with severe and difficult to treat pain, or which tends to become chronic, it may be helpful to infiltrate the region with local anesthetic. One or more uncomplicated costal fractures in subjects in good condition do not usually require hospitalization.


Sternal fractures

The violent impact of the chest against the steering wheel is the most frequent mechanism. The finding of a sternal fracture always indicates a particularly violent impact, so that injuries of the heart or pericardium, which in reality are very rare, should be excluded. Dual-projection radiography (A-P and L-L) usually confirms the presence of the fracture line, which is usually transverse and rarely offset. The pulmonary parenchyma should also be evaluated for possible contusions and the cardiac shadow for hemopericardium and tamponade. An ecg and the enzymatic dosage (myoglobin and troponin), also in young people, are used to evaluate possible cardiac contusions. The ecgraphic changes are very similar to those of the anterior ischemia. The sternal fracture is particularly painful, even after some time if there is no progressive realignment of the stumps.

Flail chest

Fractures in multiple points of at least three adjacent ribs may result in a movable parietal flap or a flail chest. The flail can be lateral, anterior and posterior (the first is greater due to the wide mobility of this parietal zone, the third is less serious due to the large rear musculature which, by "fixing" it, leads to less extensive excursions). The flap follows a paradoxical movement with respect to the dynamics of the rest of the thorax, that is, it falls within each breath and protrudes during expiration. It causes reduction of the current volume and increase of functional dead space, for the creation of a pendular movement of the air from one lung to the other that progressively becomes oxygen depleted. Moreover, like pnx, it causes a mediastinal flagging that affects the venous return. This movement is all the more accentuated and harmful as many consecutive coasts are affected by multiple fractures. Venous structures, particularly hollow veins, are affected by paradoxical motion since they can be compressed by the movement of the mediastinum against the opposite pulmonary ile. The circulatory dynamics can be altered until the slowed down or lack of venous return to the right heart cavities, resulting in cariogenic shock and sharp decline in cardiac output and systemic arterial pressure. The paradoxical breath does not manifest itself immediately after the trauma, but after a few hours. The patency of the respiratory tree compensates for a while the anomalous movement, but if flogistic or septic complications arise, the polypnea that is established accentuates the respiratory excursions, and triggers a vicious circle that quickly leads to respiratory failure with an asphyxiated and cardiac collapse. circulatory. The diagnosis of thoracic volect is clinical, the more evident the wider the area of ​​pre-natural mobility (number of ribs affected by fractures); however, the radiograph can well describe costal fractures and the presence of the rib flap, before the clinical picture manifests itself in its importance. The first aid consists in blocking the paradox movement of the flap, placing a compression on it so that the same remains as "retracted" as possible, or by applying a bandage to the Desault which partially blocks the excursion towards the outside. It may be appropriate to administer oxygen therapy, while definitive treatments are prolonged intubation and subsequent surgical fixation with Judet's agraphes or Kirschner's nails.

Classification of the flail

Anterior or sternochondral flail. It is accompanied by injury of both pleural cavities and its prognosis is severe
Side or purely costal flail. Depending on the size and place of impact, the flail can be variable
Backward volatility: infrequent, the paradoxical movement may not be appreciated, especially if the patient is supine or if the dorsal muscle or the scapula limits the flail.
Mixed flail

Diagnosis

It makes use of the clinic, the experience of the doctor and his preparation. In any case, a good inspection and palpation of the thorax may be necessary for diagnosis. Then we proceed with the instrumental investigations:
-Radiography of the thorax
-TC of the thorax
Monitoring of the patient
Patient monitoring is important for vital and bohemal parameters; the pulse oximetry allows to have a first approach, considering the pulmonary ventilation and the saturation in oxygen, if it is less than 80%, with prescription of resuscitation maneuvers. The hemogas analysis allows to evaluate the partial pressure of gases and the value of Ph and bicarbonates, especially in a patient who was already included in the bronchopathic patients. Following it is good practice to request the values ​​of myocardiospecific enzymes (CK-MB, troponin, etc.) and an ECG and echocardiogram to check for possible lesions of the heart and if there is a cardiac tamponade or hemopericardium.

Treatment

Resolve fractures, especially if multiple and / or unstable
Check if there are paradoxical movements and resolve mediastinal dislocation and normalize the negativity of endopleural pressure, especially if there are thoracic wall and pneumothorax lesions
Also treat lung parenchyma lesions, e.g. contusive traumas, lung tears, etc.
Treat the pain that certainly always complicates the breathing and the depth of breathing
Treat hemodynamic and shock conditions
to treat with antibiotics the status of pulmonary sepsis or for prophylactic purposes to prevent the development of bronchopneumonitis processes in parts of the lung that do not ventilate and are consequently collapsed because of fractures with loss of respiratory mechanics.
Where possible it is always good to avoid the intubation of the patient with wall and volatility instability. It is also a good practice to avoid the overload of the circulation to prevent the onset of pulmonary edema.

Indications with mechanical ventilation

Patient with ventilator actions> 35 or <8 minutes
PaO2 <60 mmHg
paCO2> 55 mmHg
vital capacity <15 ml / kg
VEF1> 10 ml / kg
inspiratory force> o = -25 cm H2O
Indication to surgery
If there is no improvement in patient ventilation with Cpap or B-Level, thoracic surgery is indicated or if mechanical ventilation is contraindicated due to the flail.
If the pulmonary wall is unstable and this complicates lung ventilation
If it is necessary to intervene for the presence of other lung injuries
If the pain is intense and can not be controlled with analgesia
If a lung herniation appears

index pneumology