By: Dr. Jeffrey Skubic, Medical Director
DHR Health Level I Trauma Center
Many patients injured in blunt traumatic events such as motor vehicle collisions or large animal injuries incur broken ribs. Rib fractures can cause a good deal of pain as the broken bones move with every breath. For severely displaced fractures, this can be extremely painful as the sharp edges of broken ribs can irritate surrounding soft tissues and nerves. Most of the time, rib fractures can be minor and non-displaced, requiring only diligent pain management and pulmonary toilet to maintain good respiratory hygiene during the extended healing process. In the geriatric population, mortality increases per each rib fracture; pulmonary complications such as pneumonia are directly correlated to the number of fractures incurred! Patients rarely die from an immediate complication from the rib fractures, but more so the pulmonary complications that develop several weeks later, such as pneumonia.
Unfortunately, some rib fractures are severe. These can be classified as displaced or simply bicortical (meaning both sides of the bone are broken for a complete break). A flail segment traditionally refers to having a group of at least three contiguous ribs, each broken in at least two parts. These can create chest wall instability, and a phenomenon known as paradoxical breathing may occur. Paradoxical breathing is when this flail segment moves in the opposite direction contrary to normal chest wall motion during breathing. Normally, with inhalation against a rigid chest wall, the chest wall will not decrease in size during inhalation, but rather will actually expand. With paradoxical breathing, the chest wall can actually decrease in diameter during inhalation secondary to the negative pressure created in the chest from diaphragmatic movement during inhalation, now pulling inward against an unstable segment of chest wall. Think of it as the chest wall collapsing in on itself when the patient inhales.
Historically, rib fractures were treated with a number of different methods of chest wall binding or stabilization in order to reduce pain. Overtime, we learned that limiting chest wall motion and therefore inspiration has a negative effect on patients. Principals now include proper pain control using a multimodality approach, deep breathing, coughing, respiratory treatments and early ambulation. With severe rib fractures, proper treatment can be difficult to attain. This requires close diligence and coordination of the nursing staff, physicians and respiratory therapists. At times, interventions such as rib blocks or epidural catheters can be utilized. The most invasive and heroic way to treat these rib fractures is with surgical rib stabilization. The current way of doing this is using titanium plates to reduce and stabilize fractures. This typically takes several hours to complete the surgery depending on severity of the rib fractures. The benefits that have been shown from surgically fixing these fractures are a reduced number of days on the ventilator, decreased hospital length of stay and improved pain scores. After the initial recovery from the post-operative discomfort, most patients find their pain is much less with a stable chest wall. Typically, what we have been seeing is a complete recovery in about six weeks for younger patients, as opposed to about six months without fixing the fractures, many times leading to a dependency on narcotics by this time as well. The outcomes have been promising.
Rib fractures, especially in geriatric patients can have terrible consequences. DHR Health Level I Trauma Center has multiple ways of treating rib fractures. If you or a loved one would like more information about the DHR Health Level I Trauma Center or about the fall and injury prevention education available to the community, please call, (956) 362-5119.