WBR288

Author	[[PageAuthor::Gonzalo A. Romero, M.D. [1]]]
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Surgery
Sub Category	SubCategory::Musculoskeletal/Rheumatology
Prompt	[[Prompt::A 72-year-old male falls at home and hits his right chest wall against the bed frame. He is brought to the ER after his wife called 911. His vitals are T 37C, 86 bpm, 21 respirations/min, BP: 126/80 mmHg. His head, eyes, ears, nose and throat are unremarkable. His carotid pulse is 2+ without bruits. His chest is symmetric with decreased expansion on the right side. Upon palpation he has exquisite tenderness over the eight right rib at the anterior axillary line level. His lungs are clear to auscultation and percussion bilaterally. The rest of the physical exam is unremarkable. A chest x-ray reveals a rib fracture and no other abnormal findings. Which of the following is the most appropriate management in this patient?]]
Answer A	AnswerA::Oral NSAIDs
Answer A Explanation	[[AnswerAExp::Incorrect. Oral NSAIDs may slightly control the pain associated with a plain rib fracture, but it is not enough to prevent the hypoventilation which could lead to pneumonia, specially in the elderly.]]
Answer B	AnswerB::Positive airway pressure
Answer B Explanation	[[AnswerBExp::Incorrect. It is used primarily in the treatment of sleep apnea.]]
Answer C	AnswerC::Observation
Answer C Explanation	[[AnswerCExp::Incorrect.]]
Answer D	AnswerD::Intercostal nerve block
Answer D Explanation	[[AnswerDExp::Correct.]]
Answer E	AnswerE::Oral narcotic therapy
Answer E Explanation	[[AnswerEExp::Incorrect. This can worsen the hypoventilation caused by the pain which can increase the risk of developing pneumonia.]]
Right Answer	RightAnswer::D
Explanation	[[Explanation::This elderly patient following a fall presents with a right 8th rib fracture which is limiting his right hemithorax expansion due to pain. The most appropriate management is local pain relief by nerve block and epidural catheter. After this the patient should be observed for 24 hours. If left untreated, a rib fracture can cause splinting leading to hypoventilation in the affected area. The hypoventilation could lead to pneumonia. A rib fracture can be complicated also by atelectasis and a pulmnonary contusion. Educational Objective: A plain rib fracture is the most common chest injury A rib fracture can cause hypoventilation due to pain (specially in the elderly) leading to pneumonia if left untreated References:Master the Boards for Step 2CK, Surgery Chapter See also: Rib fracture Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::Rib fracture, WBRKeyword::chest trauma, WBRKeyword::narcotics, WBRKeyword::intercostal nerve block
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::