Fixing Rib Fractures

Did you ever break a rib? 

As trauma nurses, first we look for signs that the rib punctured a lung - which would lead to a pneumothorax. Difficulty breathing after a rib injury may mean that your lung has collapsed and you need a chest tube.

However, difficulty breathing after a rib injury may be just because it hurts like Hell every time you breathe. Our intercostal muscles expand and contract our rib cage every time we inhale or exhale. 

Rib pain leads to shallow breathing. Shallow breathing leads to lung collapse or fluid accumulating in the lower lobes of the lungs, and that leads to pneumonia and other complications. 

We recently had a rib fracture specialist from Dr.John Mayberry Oregon Health Science University come and talk to the staff at our hospital. 

Here are a few of the takeaways:

• It is going to hurt - expect the pain to last for 3 to 4 months and it will take at least 50 days to get back to normal activity. 
• Toradol can help in the initial phase and Lidocaine patches can work too. 
• Incentive Spirometer, Cough and Deep Breathe ... but you already knew that. Respiratory, PT and OT is important to avoid complications. Get them out of bed and keep 'em moving. 
• Physiologic reserve - this drops after the age of 65 and means that you should admit patients with three or more rib fractures. Older than 65 and more than 6 fractured ribs is associated with a higher morbidity and mortality. Of course, with that mechanism, there is also the likelihood of multiple injuries.   

Why don't we internally fixate rib fractures like other broken bones? Mayberry is leading a study group on surgical and outpatient management of rib fractures. According to the OHSU website:

“Historically, physicians have been taught that nothing can be done to fix a rib fracture,” said John Mayberry, M.D., principal investigator of the study and associate professor of surgery in the OHSU School of Medicine. “My colleagues and I have long thought that wasn’t true, but we have yet to prove it. With this study, we hope to identify subsets of people who respond better to surgical repair than nonsurgical therapy, then develop a standard criteria for treatment.” 

Like clavicle fractures, rib fractures are one of those traumatic injuries we've always assumed healed best when left alone. We give patients tons of narcotics and tell them to cough and deep breathe. It takes a long time for these method to work.

  “Based on findings from our previous research, we are convinced that current, traditional nonsurgical management of rib fractures does not facilitate pain relief or a speedy return to normal activity. We believe new strategies, including a minimally invasive surgical method we’ve developed, will alleviate pain and reduce disability for individual participants,” said Mayberry, adding that patients in the United States disabled by acute rib fractures collectively lose approximately 58,000 years of productive work each year.

Trauma Rads

First up after registration is a Radiology Review. Frankly CT scans and Ultrasounds look like Rorschach's tests to me. I can see something when the doc or the CT tech points it out, but on my own I'm never quite sure what I'm looking at. Oh, I can spot a brain-bleed and a broken leg most times but not much more than that. 

Radiology review seems like it primary designed for the providers -- the panel is two radiologists and two surgeons. They argue enough for me to realize that I'm not the only one who has trouble picking up on the difference between a subtle pneumo and a skin fold. 

We get to see some impressive sternal fractures and one of the radiologists gives us tips on how to spot them by the high density blood behind the sternum.  Apparently these are often found as seatbelt injuries. 

The subject changes to unexpected Pulmonary Embolisms -- the majority of which are incidental. 

One of the surgeons on the panel says that fractures damage the bone marrow, which of course is full of ebolitic material. There is also a spike in the coagulation factors right after a trauma. Studies have shown that hypercoagulability is highest in the 24 hours after the traumatic event then decreases over a period of about three days. So why do some patients throw a PE after a simple pelvis fracture and die while others suffer no ill effects? "Genetics" explains the other surgeon.  This is the "Cave Man Bonus" -- a trait that probably helped save our ancestors from the saber tooth tiger bite, but these days can cause major problems.

We look at lungs and how to tell when what appears to be a wide mediastinum is a bad thing. 

We learn the trick for finding pneumos ... look for a thin, white line with black on both sides. People have gotten chest tubes for skin folds that look like pneumos. Yikes.

We learn that fallen lung sign is a bad thing.

We see great images of chest tubes is all the wrong places. Yikes!

I've been here only a few hours and here's our first open book fracture images -- yup, that will keep me from buying a motorcycle for another few years. Poor dude lost a testicle. Note: blood at meatus = no foley, but you already knew that.

Kidneys, Spleens.

Oh, and for the record, most Rorschach images look like CT scans to me, so what do I know.