Rib fracture: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
m (Robot: Automated text replacement (-{{SIB}} +, -{{EH}} +, -{{EJ}} +, -{{Editor Help}} +, -{{Editor Join}} +))
No edit summary
 
(One intermediate revision by the same user not shown)
Line 1: Line 1:
[[File:Rb.gif|thumb|[[Rib fracture]]]]
__NOTOC__
{{Infobox_Disease |
{{Infobox_Disease |
   Name          = Rib fracture |
   Name          = {{PAGENAME}} |
   Image          = |
   Image          = |
   Caption        = |
   Caption        = |
   DiseasesDB    = 11553 |
   DiseasesDB    = |
   ICD10          = {{ICD10|S|22|3|s|20}}-{{ICD10|S|22|4|s|20}} |
   ICD10          = {{ICD10|S|42|2|s|40}}-{{ICD10|S|42|4|s|40}} |
   ICD9          = {{ICD9|807.0}}, {{ICD9|807.1}} |
   ICD9          = {{ICD9|812}} |
   ICDO          = |
   ICDO          = |
   OMIM          = |
   OMIM          = |
   MedlinePlus    = |
   MedlinePlus    = |
   eMedicineSubj  = emerg |
   eMedicineSubj  = emerg |
   eMedicineTopic = 204 |
   eMedicineTopic = 199 |
  eMedicine_mult = {{eMedicine2|orthoped|271}} {{eMedicine2|orthoped|199}} |
  MeshID        = |
}}
}}
{{SI}}
{{SI}}


{{CMG}}; {{AE}}[[User:DrMars|Mohammadmain Rezazadehsaatlou[2]]].


'''''Synonyms and Keywords:'''''
==Overview==
==Overview==
A '''rib fracture''' is a break or [[bone fracture|fracture]] in one or more of the [[bone]]s making up the [[human rib cage]].
The [[Rib fracture|Rib bone]] are known as the main structural part of the thoracic cage.  [[Rib fracture|Rib bone]] are protecting the thoracic organs such Heart, Lungs, etc, additionally, the  [[Rib fracture|Rib bone]] helps the respiration process.
 
== Historical Perspective ==
There are no reliable information regarding the historical perspective of the [[Rib fracture|Rib bone fracture]] :
== Causes ==
The main etiology of the [[Rib fracture]] is thought to be due to the any type of energy directly to the thoracic cavity or any energetic force affecting human body around the thoracic cavity such as falling,  road figthing, car accident or any type of trauma can affect this area and may lead to the bone and/or cartilage injuries of the thorax. Meanwhile, the Cardiopulmonary resuscitation (CPR) could leads to the thoracic injury with/without rib and/or sternum fractures. On the other hand, diseases such as cancer or rheumatoid arthritis could cause the [[Rib fracture]] 
 
The main cause of [[Rib fracture]] is trauma. Such as the most fractures the [[Rib  fracture]] is caused by a falling or automobile accident. Meanwhile, the normal healthy bones are extremely tough and resilient and can withstand most powerful impacts. As a person age, two factors cause higher risk of fractures :
 
* Weaker bones
* Greater risk of falling
Stress fractures as a common causes of fractures can be found due to the repeated stresses and strains. Importantly children having more physically active lifestyles than adults, are also prone to fractures. People with any underlying diseases such as osteoporosis, infection, or a tumor affecting their bones having a higher risk of fractures. As mentioned in previous chapters, this type of fracture is known as a pathological fracture. Stress fractures, which result from repeated stresses and strains, commonly found among professional sports people, are also common causes of fractures.
 
===Life-threatening Causes===
*There are no life-threatening causes of  [[Rib fracture]] ''',''' however complications resulting from [[Rib fracture]]  is common.
 
===Common Causes===
Common causes of  [[Rib fracture]]  may include:
*[[Trauma]]
 
===Less Common Causes===
Less common causes of '''[[Rib fracture]]''' include conditions that predisposes to fracture:
*[[Osteoporosis]]
*[[Osteopenia]]
*[[Malignancy|Malignancies]]
===Causes by Organ System===
 
{| style="width:80%; height:100px" border="1"
| style="width:25%" bgcolor="LightSteelBlue" ; border="1" |'''Cardiovascular'''
| style="width:75%" bgcolor="Beige" ; border="1" | No underlying causes
|-
| bgcolor="LightSteelBlue" | '''Chemical/Poisoning'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Dental'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Dermatologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Endocrine'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Environmental'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Genetic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Hematologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Iatrogenic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Infectious Disease'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
| bgcolor="Beige" | [[Osteoporosis]] and [[osteopenia]].
|-
|- bgcolor="LightSteelBlue"
| '''Neurologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
| bgcolor="Beige" | [[Osteoporosis]] and [[osteopenia]].
|-
|- bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Oncologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Ophthalmologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Psychiatric'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Pulmonary'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Sexual'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Trauma'''
| bgcolor="Beige" | Falling or car accident
|-
|- bgcolor="LightSteelBlue"
| '''Urologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Miscellaneous'''
| bgcolor="Beige" | No underlying causes
|-
|}
 
===Causes in Alphabetical Order===
List the causes of the disease in alphabetical order:
<div style="-moz-column-count:3; column-count:3;">
* [[Trauma]]
* [[Osteopenia]]
* [[Osteoporosis]]
</div>
 
== Pathophysiology ==
The main etiology of the [[Rib fracture]] is thought to thee excessive high-energy axial load to patients heel moving the the talus downward onto the Rib bone and causing the injury.
 
 
inversion stress to the ankle joint.
The ankle is more stable and resistant to eversion injuries than inversion injuries Because:
The medial malleolus is shorter than the lateral malleolus causing higher range of the invertion than evertion of the talus bone.
The deltoid ligament stabilized the medial wall of the ankle joint
 
On the other hand, the transverse malleolar, Vertical malleolar, and posterior malleolar fractures are associated with an avulsion injury, talar impaction, and other bone and/or ligamentous injury, respectively.
 
=== Mechanism ===
In 80% of ankle fractures the foot is in supination position while, in 20% of fractures the foot is in pronation position. The [[Rib fracture|Rib bone fracture]] is caused by a falling or direct trauma to the ankle joint. The form and severity of this fracture depends on the position of the ankle joint at the moment of the trauma. The ankle joint is flexible but the medial side of the ankle joint is rigid because the medial malleolus is attached to the tibia and also the medial collateral ligaments are very strong. Also, lateral wall of the ankle include: the fibula, syndesmosis and lateral collateral ligaments play important rolls in this flexibility. This lateral wall of the ankle allows the talus to move in lateral and dorsal sides easily. The fibula has no weight-bearing roll but it provide a flexible lateral support. The syndesmosis is formed by the anterior and posterior tibiofibular ligaments which is the fibrous connection between the fibula and tibia.
 
If we imagine the ankle as a ring in which bones and ligaments play an important role in the maintaining the stability of this joint. Meanwhile, if this ring is broken in one place it remains stable but when it is broken in two places, the ring is unstable and it is at the higher risk of fracture. Consequently the ankle is unstable when both the medial and the lateral malleoli are fractured.
 
=== Pathophysiology ===
Its known that the [[Rib fracture|Rib  bone fracture]] in normal healthy adults can be caused due to the high-energy trauma (e.g., motor vehicle accidents), sport related injuries, falling from height. But it should be noted that the most important Risk factors for insufficiency fractures is chronic metabolic disease such as steoporosis, osteopenia, eating-disordered behavior, higher age, prolonged corticosteroid usage, female gender, lower BMI, history of a recent falling, and prior fracture.
* The pattern of bone fracture and severity of injury depends on variety of factors such as:
** Patients age
** Patients Weight
** Patients past medical history specifically any bone diseases affecting the quality of bone (such as osteoporosis, malignancies)
** Energy of trauma
** Bone quality
** Position of the specific organ during the trauma
* The below-mentioned processes cause decreased bone mass density:
** [[Autophagy]] is the mechanism through which [[Osteocyte|osteocytes]] evade [[oxidative stress]].
** The capability of [[autophagy]] in cells decreases as they age, a major factor of [[Ageing|aging]].
** As [[Osteocyte|osteocytes]] grow, viability of cells decrease thereby decreasing the bone mass density.
 
==Differentiating [[Rib fracture|Rib  bone fracture]]  from other Diseases ==
In the orthopedic medicine its important to know that the ankle fracture should be evaluated using radiography for both confirming diagnosis and also for evaluating the surrounding tissues.
* Acute compartment syndrome of ankle joint
* Ankle Dislocation
* Soft tissue Injury around the ankle ,
* Deep Venous thrombosis
* Thrombophlebitis
* Foot Fracture
* Gout
* Pseudogout
* Rheumatoid Arthritis
* Tibia Fracture
* Fibula Fracture
* bimalleolar fracture
* trimalleolar fracture
* triplane fracture
* Tillaux fracture
* Bosworth fracture
* '''pilon fracture'''
* Wagstaffe-Le Forte fracture
* Charcot-Marie-Tooth disease: in cases with repeated ankle fractures
 
==Epidemiology and Demographics ==
 
* The [[Rib fracture|Rib bone fracture]] accounts for 2% of all fractures and also is known as the most most frequent tarsal fracture (60% of all tarsal fractures) and including the 17% of open fractures
 
==Risk Factors ==
There are different risk factors that presidpose patient for the  [[Rib fracture|Rib bone fracture]] that include:
* High-risk contact sports
* Higher age (elderly adults are higher prone to such fractures)
* Reduced bone density (osteoporosis)
* Direct blow
* Road / traffic accidents
* Falling
* Direct trauma to the ankle
* Taking part in any rough or high-impact sport
* Street fights, gunshot wounds, and domestic violence, may also cause the Ankle fracture
* Road traffic accidents.
 
== Classification  ==
 
 
==Screening==
Osteoporosis is an important risk factor for human affecting human bone especially in men with the age of older than 50 years old and [[postmenopausal]] and women.
 
Based on the [[US Preventive Services Task Force|US Preventive Services Task Force (USPSTF)]] there are three groups of patients need to be screened for the [[osteoporosis]]:
* ·       Men with no history of [[osteoporosis]]
* ·       Women with the age of 65≤ year old, with no previous history of pathological [[fracture]] due to the [[osteoporosis]]
* ·       Women with the age of <65 years, with 10-year [[fracture]] risk of not less than a 65-year-old white woman (who has not any other risk factor)
Accordingly women older than age of 50 are the main target for the [[osteoporosis]] screening. There is no specific recommendation to screen men for the [[osteoporosis]].
 
The [[USPSTF]] recommendations from 2002 included:
 
Meanwhile, there are two major modalities for the [[osteoporosis]] screening:
# ·       [[Dual energy X-ray absorptiometry|Dual energy x-ray absorptiometry (DXA)]] of the [[hip]] and [[lumbar spine]] [[bones]]
# ·       Quantitative [[ultrasonography]] of the [[Rib ]]
<nowiki>*</nowiki>It should be noted of the two above mentioned modalities for screening the ultrasonograhy is preferred to the DXA due to its lower cost, lower [[ionizing radiation]], more availability.
 
After the primary evaluation of the [[osteoporosis]], the further evaluation are required in some cases such as:
 
·       Women with normal [[bone density]] or mild [[osteopenia]]: T-score of greater than −1.50 – should have screening for 15 years.
 
·       Women with moderate [[osteopenia]]: T-score of −1.50 to −1.99 – should have screening for 5 years.
 
·       Women with advanced [[osteopenia]]: T-score of −2.00 to −2.49 - should have screening for 1 year.
 
==Natural History, Complications and Prognosis ==
 
=== Natural History ===
In cases with untreated [[Rib fracture|Rib  bone fracture]] the malunion and deformity of arm can be occurred.
 
=== Complications ===
The overall complication rate in the treatment of [[Rib fracture|Rib bone fracture]] were found in around 40% of cases:
# Neurovascular compromise: such as Ulna nerve damage
# Compartment syndrome
# Chronic disability of the DRUJ
# Physeal Injury
# Malunion of the radius
# Nonunion
# Infection
# Refracture following plate removal
# Neural injury
# Instability of the DRUJ
# Loss of Motion (Stiffness)
# Posttraumatic Arthritis
# Heterotopic Ossification
 
=== Prognosis ===
Successful treatment of [[Rib fracture|Rib bone fracture]] depends on the on-time interventions such as: accurate diagnosis and appropriate treatment and referral. Complex open fractures with  soft-tissue injuries have a worse prognosis than isolated closed [[Rib fracture|Rib bone fracture]].
==Diagnosis==
The diagnosis of a [[Rib fracture|Rib bone fracture]] should be confirmed using a radiographic examination.
 
==History and Symptoms ==
The related signs and symptoms include:
* Deformity
* Skin lacerations
* Open fractures
* Erythema
* Edema
* Stiffness
* Decreased range of motion
* Tenderness
* Loss of function of the leg
* Difficulties in detection of pulses
* Nerve damage
In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the ankle. In MULTI-trauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the [[compartment syndrome]], and the compartment pressures should be measured and monitored. Normally the pain and soft-tissue swelling are found at the injury site. This injury should be confirmed using a radiographic evaluations.
 
==Physical Examination==
The related signs and symptoms include:
* Edema of the ankle
** Most of the time the edema will be a non-pitting edema
** Depends on the edema extent, it may even lead to compartment syndrome in the anterior and internal compartment of the ankle
* Bruising
** As a manifestation of internal injury to the local vessels by trauma or fractures bone
* Decrease in range of motion of the ankle
** Movement of the ankle will be painful if possible at all
* [[Tenderness]]
* Deformity
** Fractured bone deformity may be touchable in the internal side of the ankle if the fracture is displaced
In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the ankle. In polytrauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the [[compartment syndrome]], and the compartment pressures should be measured and monitored.
 
Physical examination of patients with  [[Rib fracture|Rib bone fracture]] is usually remarkable for [[swelling]], [[tenderness]], [[Bruise|bruises]], [[ecchymosis]], [[deformity]] and restricted [[range of motion]] of the ankle.
 
=== Appearance of the Patient ===
* Patients with  [[Rib fracture|Rib bone fracture]] usually appears normal unless the patients had a high energy trauma causing the open wound fracture.
 
=== Vital Signs ===
* [[Pulse|Weak pulse]] may be seen when associated with [[polytrauma]].
* [[Hypotension|Low blood pressure]] with normal [[pulse pressure]] may be present due to [[compound fracture]] with [[Bleeding|blood loss]].
 
=== Skin ===
* Skin examination of patients with [[Rib fracture|Rib bone fracture]] includes:
** [[Bruise|Bruises]]
** [[Ecchymosis]]
 
=== HEENT ===
* HEENT examination of patients with [[Rib fracture|Rib bone fracture]]  usually normal.
 
=== Neck ===
* Neck examination of patients with [[Rib fracture|Rib bone fracture]] is usually normal
 
=== Lungs ===
* Pulmonary examination of patients with [[Rib  fracture|Rib bone fracture]]  usually normal
 
=== Heart ===
* Cardiovascular examination of patients with [[Rib fracture|Rib bone fracture]]  usually normal
 
=== Abdomen ===
* Abdominal examination of patients with [[Rib fracture|Rib bone fracture]] usually normal
 
=== Back ===
* Back examination of patients with [[Rib fracture|Rib bone fracture]] usually normal
 
=== Genitourinary ===
* Genitourinary examination of patients with [[Rib fracture|Rib bone fracture]] usually normal
 
=== Neuromuscular ===
* Neuromuscular examination of patients with  [[Rib fracture|Rib bone fracture]] is usually normal
* However, some patients may develop [[neuropraxia]] of the branch of the Ulnar nerve resulting in decreased sensation of thumb, index and middle finger.
 
==Laboratory Findings==
There is a limited laboratory tests useful in the diagnosis of bone fractures such as the [[Rib fracture|Rib  bone fracture]]. Meanwhile, aged men and women may have some abnormalities in their laboratory findings suggestive of osteoporosis.
 
Laboratory tests for the diagnosis of osteoporosis are:
* Complete blood count (CBC)
* Serum total calcium level
* Serum Ionized calcium level
* Serum phosphate level
* Serum alkaline phosphatase level
* Serum 25-(OH)-vitamin D level
 
==X Ray==
There are two main markers regarding the Rib fracture in orthopedic medicine called:
 
 
The orthopedic surgeon should consider to have at least two radiographic projections (ie, anteroposterior [AP] and lateral) of the ankle. These show the fracture, the extent of displacement, and the extent of comminution. The orthopedic surgeon should pay serious attention toward finding any foreign bodies in open fractures and gunshot injuries. Also imperative is to include the elbow and wrist joint in the radiographs of [[Rib fracture|Rib bone fracture]] to ensure that the distal radioulnar joint injuries are not missed.
 
<gallery perrow="3">
File:X1.jpg| Calcaneal fracture with decreased Bohler's angle.
File:X2.jpg| Calcaneal fracture with decreased Bohler's angle.
File:X3.jpg| Avulsion fracture at the insertion of the Achilles tendon, with marked separation of fragments.
 
</gallery>
 
==CT ==
* CT-scan in the case of  the [[Rib fracture|Rib bone fracture]] is the best modality if you can not have an exclusive diagnosis by X-ray itself can not be made.
 
 
<gallery perrow="3">
File:Calcaneal fracture 2a.gif|The primary fracture line involves the lateral aspect of the posterior facet of the calcaneus, making this a Sander's type 2a fracture
File:22b.gif|The right calcaneal fracture has a primary fracture line that extends into the middle of the posterior facet, making it a Sanders type 2B fracture.
 
</gallery>
 
==MRI ==
* Magnetic resonance imaging (MRI) is an expensive technique that should not be used routinely.
* MRI is a powerful diagnostic tool to assess the abnormalities of the bone, ligaments and soft tissues associated with the [[Rib fracture|Rib bone fracture]], but it is known as a limited utility in radioulnar injuries and is not indicated in uncomplicated [[Rib  fracture|Rib bone fracture]].
* Meanwhile, the MRI can be useful in in following mentioned evaluations:
* Evaluation of occult [[Bone fracture|fractures]]
* Evaluation of the post-traumatic or [[avascular necrosis]] of [[carpal bones]]
* Evaluation of [[tendons]]
* Evaluation of [[Median nerve|nerve]]
* Evaluation of [[carpal tunnel syndrome]]
 
<gallery perrow="3">
File:M00.gif| Small subtle non displaced fissure fracture of persistent dark signal intensity is seen traversing the anterior beak of the Rib bone with surrounding extensive marrow edema signal eliciting high signal at STIR WI.
File:M0.png|Small subtle non displaced fissure fracture of persistent dark signal intensity is seen traversing the anterior beak of the Rib bone with surrounding extensive marrow edema
 
</gallery>
 
==Other Imaging Findings==
 
<gallery perrow="3">
File:N1.jpg| Dynamic flow and blood pool images show increased perfusion and vascularity at the right heel. Delayed static images show an intense increase in tracer uptake localized to the posterior aspect of the right calcaneum highly suspicious of a fracture.
File:N2.jpg| Dynamic flow and blood pool images show increased perfusion and vascularity at the right heel. Delayed static images show an intense increase in tracer uptake localized to the posterior aspect of the right calcaneum highly suspicious of a fracture.
</gallery>
 
==Other Diagnostic Studies==
There are no other Diagnostic studies associated with  [[Rib fracture|Rib bone fracture]]
 
==Treatment ==
Immediate stabilization of patients is the first step. Then the radial fracture and the DRUJ stabilization is recommended in these cases. Open ankle fractures considered as a surgical emergency. [[Rib fracture|Rib  bone fracture]] occurs in younger patients who are skeletally immature; the normally they treated using a closed reduction and casting. Since closed reduction and cast application have led to unsatisfactory results. Then, Almost always the open reduction are necessary for the [[Rib fracture|Rib  bone fracture]]. There are controversies regarding the indications for intramedullary nailing of ankle fractures.
 
==Non-Operative Treatment ==
* The first step in managing a patient with a fracture is to stabilize the patient if he/she is unstable due to blood loss, etc by giving them intravenous fluids and giving them some painkillers if the pain is severe.
* In children, the usual plan is to attempt closed reduction followed by cast immobilization. In adults, treatment with immobilization in a molded long arm cast can be used in those rare occasions of a non-displaced fracture of the ankle joint. If the fracture shifts in position, it may require surgery to put the bones back together.
* Rigid immobilization is suggested in preference to removable splints in nonoperative treatment for the management of the [[Rib fracture|Rib bone fracture]]
* For all patients with [[Rib fracture|Rib bone fracture]], a post-reduction true lateral [[Radiography|radiograph]] is suggested.
* Operative fixation is suggested in preference to [[Orthopedic cast|cast]] fixation for fractures with post-reduction radial [[shortening]] greater than 3 mm, dorsal tilt greater than 10º, or intra-articular displacement or step-off greater than 2 mm.
* Patients probably do not need to begin early wrist motion routinely after stable [[Bone fracture|fracture]] fixation.
* Adjuvant treatment of [[Rib  fracture|Rib bone fracture]] with vitamin C is suggested for the prevention of disproportionate [[pain]]
* Lateral epicondylar fractures should be immobilized for 7 days with patients elbow flexed at 90º, with the supinated ankle , and the extended wrist for relaxing the extensor muscles.
=== Complications of Non-surgical therapy ===
Failure of non-surgical therapy is common:
* Re-displacement to its original position even in a cast
* [[Stiffness]]
* Post traumatic [[osteoarthritis]] leading to wrist pain and loss of function
* Other risks specific to cast treatment include:
** Compression of the swollen arm causing [[compartment syndrome]]
** [[Reflex sympathetic dystrophy]] is a serious complication
** Stiffness is universal following a prolonged period of immobilization and swelling
 
==Surgery <ref name="pmid6584293">{{cite journal |vauthors=Masztalerz A, Bujwidowa B, Jagielska I, Masztalerzowa Z, Potoczek J, Szczepańska H, Warych B |title=[Social class and dental and occlusal conditions] |language=Polish |journal=Czas Stomatol |volume=36 |issue=9 |pages=691–5 |date=September 1983 |pmid=6584293 |doi= |url=}}</ref>==
Returning to the normal physical activity after [[Rib fracture|Rib bone fracture]] can take weeks to months of therapy under supervision an orthopedist. Meanwhile, a physiotherapy can be helpful for patient to achieve the normal wrist and elbow function caused by the immobilisation. All adult [[Rib fracture|Rib bone fracture]] should be considered to be treated with open reduction and internal fixation (ORIF).
 
<gallery perrow="3">
File:S1.jpg|Post operation Calcaneal fracture
File:S2.jpg|Post operation Calcaneal fracture
File:S3.jpg|Post operation Calcaneal fracture
</gallery>
 
 
 
External fixation: For severe open fractures
Open reduction and internal fixation: For [[Rib fracture|Rib bone fracture]] which depending on each patients condition the following may be needed:
 
Nerve placement
Bone grafting
Osteotomy
Arthrodesis
 
 
=== Operation ===
* There are a variety of methods and implants useful to stabilize the  [[Rib fracture|Rib bone fracture]], ranging from closed reduction and percutaneous pin fixation to the use of intra-medullary devices.
* However, the most common fixation methods to treat complex [[Rib  fracture|Rib bone fracture]] include [[external fixation]], and open reduction and internal fixation.
 
=== External Fixation With or Without Percutaneous Pin Fixation ===
* [[Ankle]] spanning [[external fixation]] employs ligamentotaxis to restore and maintain length, alignment, and rotation of bone.
* Reduction is typically obtained through closed or minimally open methods and preserves the [[Bone fracture|fracture]] biology.
* The addition of percutaneous pins enhances the ability to reduce and stabilize fracture fragments.
 
==== Complications of External Fixation ====
* Pin tract [[infection]]
* Injury to the [[Superficial branch of the  nerve]]
* [[Complex regional pain syndrome]]
 
=== Open reduction and internal fixation with plates and screws ===
* This is the most common type of surgical repair for  [[Rib  fracture|Rib bone fracture]]
* During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment.
* The bones held together with special screws and metal plates attached to the outer surface of the bone.
 
==== Complications of open reduction and internal fixation with plates and screws =====
* Infection
* Damage to nerves and blood vessels
* Synostosis
* Nonunion
 
=== Pain Management ===
Pain after an injury or surgery is a natural part of the healing process.
 
Medications are often prescribed for short-term pain relief after surgery or an injury such as:
* opioids
* non-steroidal anti-inflammatory drugs (NSAIDs)
* local anesthetics


* The ''[[first rib]]'' is rarely fractured because of its protected position behind the [[clavicle]] (collarbone). However, if it is broken serious damage can occur to the [[brachial plexus]] of [[nerve]]s and the [[subclavian]] vessels.
=== Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and can be addictive.  It is important to use opioids only as directed by doctor. ===


* The ''middle ribs'' are the ones most commonly fractured. Fractures usually occur from direct blows or from indirect crushing injuries. The weakest part of a rib is just anterior to its angle, but a fracture can occur anywhere.
=== Interventions ===
The following options can be helpful for patients to rehabilitate after their fracture :
* Joints mobilization
* compression bandage
* Soft tissue massage
* Exercises and Activity modification


* A ''lower rib'' fracture has the complication of potentially injuring the [[diaphragm (anatomy)|diaphragm]], which could result in a [[diaphragmatic hernia]].
== Postoperative Rehabilitation  ==
* Complex  [[Rib fracture|Rib bone fracture]] warrant individualized immobilization and rehabilitation strategies.
* Because most multifragmentary [[Rib fracture|Rib bone fracture]] are the result of high-energy injuries, a prolonged period of [[wrist]] immobilization and [[Soft tissue|soft-tissue]] rest may be beneficial and has not been shown to affect clinical outcomes.
* The ankle is typically immobilized for 6 weeks post-operatively in a [[Splint (medicine)|splint]] with Full weight bearing commences at approximately 3 months post-operatively after consolidation of the [[Bone fracture|fracture]] is noted on radiographs.
*<nowiki/>The presence of varying degrees of ankle [[stiffness]] is inevitable and may result from poor [[pain]] control, lack of effort in controlled mobilization, [[edema]], concomitant ipsilateral [[lower extremity]] [[Bone fracture|fracture]]<nowiki/>s, or [[Peripheral nervous system|peripheral]] <nowiki/>[[Peripheral nervous system|nerve]] injuries. Early stretching and mobilization of the intrinsic and extrinsic [[Tendon|tendons]] of the [[hand]] is important to prevent finger [[stiffness]].  [[Edema]] control can be initiated with compression gloves, digital massage, and active and passive ROM of the ankle. A home [[Physical exercise|exercise]] program or outpatient occupational therapy is started immediately post-operatively to maintain full [[range of motion]] of the ankle and limit the development of intrinsic muscle tightnes


Rib fractures are usually quite painful because the ribs have to move to allow for [[Breath|breathing]].  Even a small crack can inflame a tendon and cripple an arm.
== Primary Prevention ==
There are various preventive options to reduce the incidence of the [[Rib fracture|Rib bone fracture]]
* Using ankle guards during practicing sports (skating, biking)
* Using ankle guards during driving motorbikes
* Avoid falls in elderly individuals
* Prevention and/or treatment of osteoporosis
*<nowiki/><nowiki/><nowiki/>Healthy diet


When several ribs are broken in several places a [[flail chest]] results, and the detached bone sections will move separately from the rest of the chest.
== Secondary Prevention ==
It should be noted that the Post-menopausal women specially older than the age of 65 are at the higher risk of [[osteoporosis]] consequently these type of patients at greater risk for the pathological [[Bone fracture|fractures]] .


==Causes==
So the [[Calcium]] and [[vitamin D]] supplementation play important role in increasing the [[Bone mineral density|bone mineral density (BMD]]) consequently decrease the risk of fracture in these type of patients. Also, avoiding excessive [[alcohol]] and quitting [[smoking]] play important role in this regard.
Rib fractures can occur without direct trauma and have been reported after sustained [[cough]]ing and in various [[sport]]s &ndash; for example, [[rowing (sport)|rowing]] and [[golf]] &ndash; often in elite [[sportsperson|athlete]]s. They can also occur as a consequence of diseases such as cancer or infections ([[pathological fracture]]).


Fragility fractures of ribs can occur due to diseased bone structure, e.g., [[osteoporosis]] and [[metastasis|metastatic]] deposits.
=== Detecting osteoporosis===
* [[Dual energy X-ray absorptiometry|DEXA]](dual-energy x-ray absorptiometry) scan
* Serum [[calcium]] and [[vitamin D]] levels
* [[Medical ultrasonography|Ultrasonography]] of the [[Rib ]]


== Diagnosis ==
=== Pharmacological therapy ===
* The primary goal for the treatment of [[osteoporosis]] is to reduce longtime [[fracture]] risk in patients. Increasing [[Bone mineral density|bone mineral density (BMD)]] in response to the treatment is far less important than improvement of clinical aspects of [[osteoporosis]], i.e., [[Osteoporosis|osteoporotic]][[Bone fracture|fracture]]. Therefore, most of the [[drugs]] efficacy is measured by the extent they improve the [[fracture]] risk instead of increasing [[Bone mineral density|BMD]].
* During the treatment, if a single [[fracture]] happens, it does not necessarily indicate treatment failure or the need to be started on an alternative treatment or patient referral to a [[specialist]].
* [[Calcium]] and [[vitamin D]] supplementation have been found to be effective in reducing the long term [[Bone fracture|fracture]] risk, significantly. In order to suggest the people to use [[vitamin D]] and [[calcium]] [[supplements]], the [[physician]] needs to make sure that patient is not able to obtain the [[nutrients]] through the daily intake. The available supplemental ions of [[calcium]] include [[calcium carbonate]], [[Calcium citrate|calcium citrate,]] and [[vitamin D3]] in various [[Dosage form|dosage forms]].


Broken ribs are often indicated by the following [[symptom]]s:
=== Life style modifications===
* [[Exercise]]: Exercise promotes the [[mineralization]] of [[bone]] and [[bone]] accumulation particularly during growth. High impact exercise, in particular, has been shown to prevent the development of [[osteoporosis]]. However, it can have a negative effect on bone [[mineralization]] in cases of poor [[nutrition]], such as [[anorexia nervosa]] and [[celiac disease]].
* [[Nutrition]]: A [[diet]] high in [[calcium]] and [[vitamin D]] prevents [[bone loss]]. Patients at risk for [[osteoporosis]], such as persons with chronic [[steroid]] use are generally treated with [[vitamin D]] and [[calcium]] supplementation. In [[Kidney|renal]] disease, more active forms of [[vitamin D]], such as 1,25-dihydroxycholecalciferol or [[calcitriol]] are used; as the kidney cannot adequately generate [[calcitriol]] from [[calcidiol]] (25-hydroxycholecalciferol), which is the storage form of [[vitamin D]].
* By quitting [[smoking]], [[osteoporosis]] as well as other diseases can be prevented.
* Avoiding excessive [[alcohol]] intake or drinking only in moderation.


* Pain when breathing or with movement
* A portion of the chest wall moving separately from the rest of the chest (flail chest)
* A grating sound with breathing or movement
* Where the [[mechanism of injury]] would indicate substantial force to the ribs


==Treatment==


There is no specific treatment for rib fractures, but various supportive measures can be taken. In simple rib fractures, pain can lead to reduced movement and cough suppression; this can contribute to formation of secondary chest infection. Adequate [[analgesic|analgesia]] can avoid this.
{{WH}}
{{WS}}


Flail chest is a potentially life-threatening injury and will often require a period of [[mechanical ventilation|assisted ventilation]]. Flail chest and first rib fractures are high-energy injuries and should prompt investigation of damage to underlying [[viscus|viscera]] (e.g., lung [[bruise|contusion]]) or remotely (e.g., C spine injury).


Spontaneous fractures in sportspeople generally require a cessation of the cause, e.g., time off rowing, whilst maintaining cardiovascular fitness.
==References==
<references />


{{Fractures}}


__NOTOC__


[[Category:Chest trauma]]
==See also==
[[Category:Fractures]]


[[de:Rippenfraktur]]
* [[Category:Emergency medicine]]
[[ru:Переломы рёбер]]
* [[Category:Orthopedics]]
* [[Category:Bone fractures]]
* [[Category:Chest trauma]]
* [[Category:Fractures]]


{{WH}}
{{WH}}
{{WS}}
{{WS}}

Latest revision as of 18:50, 17 March 2020

Rib fracture
Rib fracture
ICD-10 S42.2-S42.4
ICD-9 812
eMedicine emerg/199  orthoped/271 orthoped/199

WikiDoc Resources for Rib fracture

Articles

Most recent articles on Rib fracture

Most cited articles on Rib fracture

Review articles on Rib fracture

Articles on Rib fracture in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Rib fracture

Images of Rib fracture

Photos of Rib fracture

Podcasts & MP3s on Rib fracture

Videos on Rib fracture

Evidence Based Medicine

Cochrane Collaboration on Rib fracture

Bandolier on Rib fracture

TRIP on Rib fracture

Clinical Trials

Ongoing Trials on Rib fracture at Clinical Trials.gov

Trial results on Rib fracture

Clinical Trials on Rib fracture at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Rib fracture

NICE Guidance on Rib fracture

NHS PRODIGY Guidance

FDA on Rib fracture

CDC on Rib fracture

Books

Books on Rib fracture

News

Rib fracture in the news

Be alerted to news on Rib fracture

News trends on Rib fracture

Commentary

Blogs on Rib fracture

Definitions

Definitions of Rib fracture

Patient Resources / Community

Patient resources on Rib fracture

Discussion groups on Rib fracture

Patient Handouts on Rib fracture

Directions to Hospitals Treating Rib fracture

Risk calculators and risk factors for Rib fracture

Healthcare Provider Resources

Symptoms of Rib fracture

Causes & Risk Factors for Rib fracture

Diagnostic studies for Rib fracture

Treatment of Rib fracture

Continuing Medical Education (CME)

CME Programs on Rib fracture

International

Rib fracture en Espanol

Rib fracture en Francais

Business

Rib fracture in the Marketplace

Patents on Rib fracture

Experimental / Informatics

List of terms related to Rib fracture

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou[2].

Synonyms and Keywords:

Overview

The Rib bone are known as the main structural part of the thoracic cage. Rib bone are protecting the thoracic organs such Heart, Lungs, etc, additionally, the Rib bone helps the respiration process.

Historical Perspective

There are no reliable information regarding the historical perspective of the Rib bone fracture :

Causes

The main etiology of the Rib fracture is thought to be due to the any type of energy directly to the thoracic cavity or any energetic force affecting human body around the thoracic cavity such as falling, road figthing, car accident or any type of trauma can affect this area and may lead to the bone and/or cartilage injuries of the thorax. Meanwhile, the Cardiopulmonary resuscitation (CPR) could leads to the thoracic injury with/without rib and/or sternum fractures. On the other hand, diseases such as cancer or rheumatoid arthritis could cause the Rib fracture

The main cause of Rib fracture is trauma. Such as the most fractures the Rib fracture is caused by a falling or automobile accident. Meanwhile, the normal healthy bones are extremely tough and resilient and can withstand most powerful impacts. As a person age, two factors cause higher risk of fractures :

  • Weaker bones
  • Greater risk of falling

Stress fractures as a common causes of fractures can be found due to the repeated stresses and strains. Importantly children having more physically active lifestyles than adults, are also prone to fractures. People with any underlying diseases such as osteoporosis, infection, or a tumor affecting their bones having a higher risk of fractures. As mentioned in previous chapters, this type of fracture is known as a pathological fracture. Stress fractures, which result from repeated stresses and strains, commonly found among professional sports people, are also common causes of fractures.

Life-threatening Causes

Common Causes

Common causes of Rib fracture may include:

Less Common Causes

Less common causes of Rib fracture include conditions that predisposes to fracture:

Causes by Organ System

Cardiovascular No underlying causes
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal/Orthopedic Osteoporosis and osteopenia.
Neurologic No underlying causes
Nutritional/Metabolic Osteoporosis and osteopenia.
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte No underlying causes
Rheumatology/Immunology/Allergy No underlying causes
Sexual No underlying causes
Trauma Falling or car accident
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order

List the causes of the disease in alphabetical order:

Pathophysiology

The main etiology of the Rib fracture is thought to thee excessive high-energy axial load to patients heel moving the the talus downward onto the Rib bone and causing the injury.


inversion stress to the ankle joint. The ankle is more stable and resistant to eversion injuries than inversion injuries Because: The medial malleolus is shorter than the lateral malleolus causing higher range of the invertion than evertion of the talus bone. The deltoid ligament stabilized the medial wall of the ankle joint

On the other hand, the transverse malleolar, Vertical malleolar, and posterior malleolar fractures are associated with an avulsion injury, talar impaction, and other bone and/or ligamentous injury, respectively.

Mechanism

In 80% of ankle fractures the foot is in supination position while, in 20% of fractures the foot is in pronation position. The Rib bone fracture is caused by a falling or direct trauma to the ankle joint. The form and severity of this fracture depends on the position of the ankle joint at the moment of the trauma. The ankle joint is flexible but the medial side of the ankle joint is rigid because the medial malleolus is attached to the tibia and also the medial collateral ligaments are very strong. Also, lateral wall of the ankle include: the fibula, syndesmosis and lateral collateral ligaments play important rolls in this flexibility. This lateral wall of the ankle allows the talus to move in lateral and dorsal sides easily. The fibula has no weight-bearing roll but it provide a flexible lateral support. The syndesmosis is formed by the anterior and posterior tibiofibular ligaments which is the fibrous connection between the fibula and tibia.

If we imagine the ankle as a ring in which bones and ligaments play an important role in the maintaining the stability of this joint. Meanwhile, if this ring is broken in one place it remains stable but when it is broken in two places, the ring is unstable and it is at the higher risk of fracture. Consequently the ankle is unstable when both the medial and the lateral malleoli are fractured.

Pathophysiology

Its known that the Rib bone fracture in normal healthy adults can be caused due to the high-energy trauma (e.g., motor vehicle accidents), sport related injuries, falling from height. But it should be noted that the most important Risk factors for insufficiency fractures is chronic metabolic disease such as steoporosis, osteopenia, eating-disordered behavior, higher age, prolonged corticosteroid usage, female gender, lower BMI, history of a recent falling, and prior fracture.

  • The pattern of bone fracture and severity of injury depends on variety of factors such as:
    • Patients age
    • Patients Weight
    • Patients past medical history specifically any bone diseases affecting the quality of bone (such as osteoporosis, malignancies)
    • Energy of trauma
    • Bone quality
    • Position of the specific organ during the trauma
  • The below-mentioned processes cause decreased bone mass density:

Differentiating Rib bone fracture from other Diseases

In the orthopedic medicine its important to know that the ankle fracture should be evaluated using radiography for both confirming diagnosis and also for evaluating the surrounding tissues.

  • Acute compartment syndrome of ankle joint
  • Ankle Dislocation
  • Soft tissue Injury around the ankle ,
  • Deep Venous thrombosis
  • Thrombophlebitis
  • Foot Fracture
  • Gout
  • Pseudogout
  • Rheumatoid Arthritis
  • Tibia Fracture
  • Fibula Fracture
  • bimalleolar fracture
  • trimalleolar fracture
  • triplane fracture
  • Tillaux fracture
  • Bosworth fracture
  • pilon fracture
  • Wagstaffe-Le Forte fracture
  • Charcot-Marie-Tooth disease: in cases with repeated ankle fractures

Epidemiology and Demographics

  • The Rib bone fracture accounts for 2% of all fractures and also is known as the most most frequent tarsal fracture (60% of all tarsal fractures) and including the 17% of open fractures

Risk Factors

There are different risk factors that presidpose patient for the Rib bone fracture that include:

  • High-risk contact sports
  • Higher age (elderly adults are higher prone to such fractures)
  • Reduced bone density (osteoporosis)
  • Direct blow
  • Road / traffic accidents
  • Falling
  • Direct trauma to the ankle
  • Taking part in any rough or high-impact sport
  • Street fights, gunshot wounds, and domestic violence, may also cause the Ankle fracture
  • Road traffic accidents.

Classification

Screening

Osteoporosis is an important risk factor for human affecting human bone especially in men with the age of older than 50 years old and postmenopausal and women.

Based on the US Preventive Services Task Force (USPSTF) there are three groups of patients need to be screened for the osteoporosis:

  • ·       Men with no history of osteoporosis
  • ·       Women with the age of 65≤ year old, with no previous history of pathological fracture due to the osteoporosis
  • ·       Women with the age of <65 years, with 10-year fracture risk of not less than a 65-year-old white woman (who has not any other risk factor)

Accordingly women older than age of 50 are the main target for the osteoporosis screening. There is no specific recommendation to screen men for the osteoporosis.

The USPSTF recommendations from 2002 included:

Meanwhile, there are two major modalities for the osteoporosis screening:

  1. ·       Dual energy x-ray absorptiometry (DXA) of the hip and lumbar spine bones
  2. ·       Quantitative ultrasonography of the Rib

*It should be noted of the two above mentioned modalities for screening the ultrasonograhy is preferred to the DXA due to its lower cost, lower ionizing radiation, more availability.

After the primary evaluation of the osteoporosis, the further evaluation are required in some cases such as:

·       Women with normal bone density or mild osteopenia: T-score of greater than −1.50 – should have screening for 15 years.

·       Women with moderate osteopenia: T-score of −1.50 to −1.99 – should have screening for 5 years.

·       Women with advanced osteopenia: T-score of −2.00 to −2.49 - should have screening for 1 year.

Natural History, Complications and Prognosis

Natural History

In cases with untreated Rib bone fracture the malunion and deformity of arm can be occurred.

Complications

The overall complication rate in the treatment of Rib bone fracture were found in around 40% of cases:

  1. Neurovascular compromise: such as Ulna nerve damage
  2. Compartment syndrome
  3. Chronic disability of the DRUJ
  4. Physeal Injury
  5. Malunion of the radius
  6. Nonunion
  7. Infection
  8. Refracture following plate removal
  9. Neural injury
  10. Instability of the DRUJ
  11. Loss of Motion (Stiffness)
  12. Posttraumatic Arthritis
  13. Heterotopic Ossification

Prognosis

Successful treatment of Rib bone fracture depends on the on-time interventions such as: accurate diagnosis and appropriate treatment and referral. Complex open fractures with soft-tissue injuries have a worse prognosis than isolated closed Rib bone fracture.

Diagnosis

The diagnosis of a Rib bone fracture should be confirmed using a radiographic examination.

History and Symptoms

The related signs and symptoms include:

  • Deformity
  • Skin lacerations
  • Open fractures
  • Erythema
  • Edema
  • Stiffness
  • Decreased range of motion
  • Tenderness
  • Loss of function of the leg
  • Difficulties in detection of pulses
  • Nerve damage

In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the ankle. In MULTI-trauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the compartment syndrome, and the compartment pressures should be measured and monitored. Normally the pain and soft-tissue swelling are found at the injury site. This injury should be confirmed using a radiographic evaluations.

Physical Examination

The related signs and symptoms include:

  • Edema of the ankle
    • Most of the time the edema will be a non-pitting edema
    • Depends on the edema extent, it may even lead to compartment syndrome in the anterior and internal compartment of the ankle
  • Bruising
    • As a manifestation of internal injury to the local vessels by trauma or fractures bone
  • Decrease in range of motion of the ankle
    • Movement of the ankle will be painful if possible at all
  • Tenderness
  • Deformity
    • Fractured bone deformity may be touchable in the internal side of the ankle if the fracture is displaced

In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the ankle. In polytrauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the compartment syndrome, and the compartment pressures should be measured and monitored.

Physical examination of patients with Rib bone fracture is usually remarkable for swelling, tenderness, bruises, ecchymosis, deformity and restricted range of motion of the ankle.

Appearance of the Patient

  • Patients with Rib bone fracture usually appears normal unless the patients had a high energy trauma causing the open wound fracture.

Vital Signs

Skin

HEENT

Neck

Lungs

Heart

Abdomen

Back

Genitourinary

Neuromuscular

  • Neuromuscular examination of patients with Rib bone fracture is usually normal
  • However, some patients may develop neuropraxia of the branch of the Ulnar nerve resulting in decreased sensation of thumb, index and middle finger.

Laboratory Findings

There is a limited laboratory tests useful in the diagnosis of bone fractures such as the Rib bone fracture. Meanwhile, aged men and women may have some abnormalities in their laboratory findings suggestive of osteoporosis.

Laboratory tests for the diagnosis of osteoporosis are:

  • Complete blood count (CBC)
  • Serum total calcium level
  • Serum Ionized calcium level
  • Serum phosphate level
  • Serum alkaline phosphatase level
  • Serum 25-(OH)-vitamin D level

X Ray

There are two main markers regarding the Rib fracture in orthopedic medicine called:


The orthopedic surgeon should consider to have at least two radiographic projections (ie, anteroposterior [AP] and lateral) of the ankle. These show the fracture, the extent of displacement, and the extent of comminution. The orthopedic surgeon should pay serious attention toward finding any foreign bodies in open fractures and gunshot injuries. Also imperative is to include the elbow and wrist joint in the radiographs of Rib bone fracture to ensure that the distal radioulnar joint injuries are not missed.

  • Calcaneal fracture with decreased Bohler's angle.

    Calcaneal fracture with decreased Bohler's angle.

  • Calcaneal fracture with decreased Bohler's angle.

    Calcaneal fracture with decreased Bohler's angle.

  • Avulsion fracture at the insertion of the Achilles tendon, with marked separation of fragments.

    Avulsion fracture at the insertion of the Achilles tendon, with marked separation of fragments.

CT

  • CT-scan in the case of the Rib bone fracture is the best modality if you can not have an exclusive diagnosis by X-ray itself can not be made.


  • The primary fracture line involves the lateral aspect of the posterior facet of the calcaneus, making this a Sander's type 2a fracture

    The primary fracture line involves the lateral aspect of the posterior facet of the calcaneus, making this a Sander's type 2a fracture

  • The right calcaneal fracture has a primary fracture line that extends into the middle of the posterior facet, making it a Sanders type 2B fracture.

    The right calcaneal fracture has a primary fracture line that extends into the middle of the posterior facet, making it a Sanders type 2B fracture.

MRI

  • Magnetic resonance imaging (MRI) is an expensive technique that should not be used routinely.
  • MRI is a powerful diagnostic tool to assess the abnormalities of the bone, ligaments and soft tissues associated with the Rib bone fracture, but it is known as a limited utility in radioulnar injuries and is not indicated in uncomplicated Rib bone fracture.
  • Meanwhile, the MRI can be useful in in following mentioned evaluations:
  • Evaluation of occult fractures
  • Evaluation of the post-traumatic or avascular necrosis of carpal bones
  • Evaluation of tendons
  • Evaluation of nerve
  • Evaluation of carpal tunnel syndrome
  • Small subtle non displaced fissure fracture of persistent dark signal intensity is seen traversing the anterior beak of the Rib bone with surrounding extensive marrow edema signal eliciting high signal at STIR WI.

    Small subtle non displaced fissure fracture of persistent dark signal intensity is seen traversing the anterior beak of the Rib bone with surrounding extensive marrow edema signal eliciting high signal at STIR WI.

  • Small subtle non displaced fissure fracture of persistent dark signal intensity is seen traversing the anterior beak of the Rib bone with surrounding extensive marrow edema

    Small subtle non displaced fissure fracture of persistent dark signal intensity is seen traversing the anterior beak of the Rib bone with surrounding extensive marrow edema

Other Imaging Findings

  • Dynamic flow and blood pool images show increased perfusion and vascularity at the right heel. Delayed static images show an intense increase in tracer uptake localized to the posterior aspect of the right calcaneum highly suspicious of a fracture.

    Dynamic flow and blood pool images show increased perfusion and vascularity at the right heel. Delayed static images show an intense increase in tracer uptake localized to the posterior aspect of the right calcaneum highly suspicious of a fracture.

  • Dynamic flow and blood pool images show increased perfusion and vascularity at the right heel. Delayed static images show an intense increase in tracer uptake localized to the posterior aspect of the right calcaneum highly suspicious of a fracture.

    Dynamic flow and blood pool images show increased perfusion and vascularity at the right heel. Delayed static images show an intense increase in tracer uptake localized to the posterior aspect of the right calcaneum highly suspicious of a fracture.

Other Diagnostic Studies

There are no other Diagnostic studies associated with Rib bone fracture

Treatment

Immediate stabilization of patients is the first step. Then the radial fracture and the DRUJ stabilization is recommended in these cases. Open ankle fractures considered as a surgical emergency. Rib bone fracture occurs in younger patients who are skeletally immature; the normally they treated using a closed reduction and casting. Since closed reduction and cast application have led to unsatisfactory results. Then, Almost always the open reduction are necessary for the Rib bone fracture. There are controversies regarding the indications for intramedullary nailing of ankle fractures.

Non-Operative Treatment

  • The first step in managing a patient with a fracture is to stabilize the patient if he/she is unstable due to blood loss, etc by giving them intravenous fluids and giving them some painkillers if the pain is severe.
  • In children, the usual plan is to attempt closed reduction followed by cast immobilization. In adults, treatment with immobilization in a molded long arm cast can be used in those rare occasions of a non-displaced fracture of the ankle joint. If the fracture shifts in position, it may require surgery to put the bones back together.
  • Rigid immobilization is suggested in preference to removable splints in nonoperative treatment for the management of the Rib bone fracture
  • For all patients with Rib bone fracture, a post-reduction true lateral radiograph is suggested.
  • Operative fixation is suggested in preference to cast fixation for fractures with post-reduction radial shortening greater than 3 mm, dorsal tilt greater than 10º, or intra-articular displacement or step-off greater than 2 mm.
  • Patients probably do not need to begin early wrist motion routinely after stable fracture fixation.
  • Adjuvant treatment of Rib bone fracture with vitamin C is suggested for the prevention of disproportionate pain
  • Lateral epicondylar fractures should be immobilized for 7 days with patients elbow flexed at 90º, with the supinated ankle , and the extended wrist for relaxing the extensor muscles.

Complications of Non-surgical therapy

Failure of non-surgical therapy is common:

  • Re-displacement to its original position even in a cast
  • Stiffness
  • Post traumatic osteoarthritis leading to wrist pain and loss of function
  • Other risks specific to cast treatment include:

Surgery [1]

Returning to the normal physical activity after Rib bone fracture can take weeks to months of therapy under supervision an orthopedist. Meanwhile, a physiotherapy can be helpful for patient to achieve the normal wrist and elbow function caused by the immobilisation. All adult Rib bone fracture should be considered to be treated with open reduction and internal fixation (ORIF).

  • Post operation Calcaneal fracture

    Post operation Calcaneal fracture

  • Post operation Calcaneal fracture

    Post operation Calcaneal fracture

  • Post operation Calcaneal fracture

    Post operation Calcaneal fracture


External fixation: For severe open fractures Open reduction and internal fixation: For Rib bone fracture which depending on each patients condition the following may be needed:

Nerve placement Bone grafting Osteotomy Arthrodesis


Operation

  • There are a variety of methods and implants useful to stabilize the Rib bone fracture, ranging from closed reduction and percutaneous pin fixation to the use of intra-medullary devices.
  • However, the most common fixation methods to treat complex Rib bone fracture include external fixation, and open reduction and internal fixation.

External Fixation With or Without Percutaneous Pin Fixation

  • Ankle spanning external fixation employs ligamentotaxis to restore and maintain length, alignment, and rotation of bone.
  • Reduction is typically obtained through closed or minimally open methods and preserves the fracture biology.
  • The addition of percutaneous pins enhances the ability to reduce and stabilize fracture fragments.

Complications of External Fixation

Open reduction and internal fixation with plates and screws

  • This is the most common type of surgical repair for Rib bone fracture
  • During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment.
  • The bones held together with special screws and metal plates attached to the outer surface of the bone.

Complications of open reduction and internal fixation with plates and screws =

  • Infection
  • Damage to nerves and blood vessels
  • Synostosis
  • Nonunion

Pain Management

Pain after an injury or surgery is a natural part of the healing process.

Medications are often prescribed for short-term pain relief after surgery or an injury such as:

  • opioids
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • local anesthetics

Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and can be addictive.  It is important to use opioids only as directed by doctor.

Interventions

The following options can be helpful for patients to rehabilitate after their fracture :

  • Joints mobilization
  • compression bandage
  • Soft tissue massage
  • Exercises and Activity modification

Postoperative Rehabilitation

  • Complex Rib bone fracture warrant individualized immobilization and rehabilitation strategies.
  • Because most multifragmentary Rib bone fracture are the result of high-energy injuries, a prolonged period of wrist immobilization and soft-tissue rest may be beneficial and has not been shown to affect clinical outcomes.
  • The ankle is typically immobilized for 6 weeks post-operatively in a splint with Full weight bearing commences at approximately 3 months post-operatively after consolidation of the fracture is noted on radiographs.
  • The presence of varying degrees of ankle stiffness is inevitable and may result from poor pain control, lack of effort in controlled mobilization, edema, concomitant ipsilateral lower extremity fractures, or peripheral nerve injuries. Early stretching and mobilization of the intrinsic and extrinsic tendons of the hand is important to prevent finger stiffness. Edema control can be initiated with compression gloves, digital massage, and active and passive ROM of the ankle. A home exercise program or outpatient occupational therapy is started immediately post-operatively to maintain full range of motion of the ankle and limit the development of intrinsic muscle tightnes

Primary Prevention

There are various preventive options to reduce the incidence of the Rib bone fracture

  • Using ankle guards during practicing sports (skating, biking)
  • Using ankle guards during driving motorbikes
  • Avoid falls in elderly individuals
  • Prevention and/or treatment of osteoporosis
  • Healthy diet

Secondary Prevention

It should be noted that the Post-menopausal women specially older than the age of 65 are at the higher risk of osteoporosis consequently these type of patients at greater risk for the pathological fractures .

So the Calcium and vitamin D supplementation play important role in increasing the bone mineral density (BMD) consequently decrease the risk of fracture in these type of patients. Also, avoiding excessive alcohol and quitting smoking play important role in this regard.

Detecting osteoporosis

Pharmacological therapy

Life style modifications


Template:WH Template:WS


References

  1. ↑ Masztalerz A, Bujwidowa B, Jagielska I, Masztalerzowa Z, Potoczek J, Szczepańska H, Warych B (September 1983). "[Social class and dental and occlusal conditions]". Czas Stomatol (in Polish). 36 (9): 691–5. PMID 6584293.



See also

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Rib_fracture&oldid=1602569"