RIB AND STERNUM FRACTURES

Rib fracture is a complete or incomplete fracture of any of the 12 ribs on either side
and soft tissue surrounding the fracture site, including nerves, tendons, ligaments,
cartilage and blood vessels. Most rib fractures are accompanied by sprain or rupture of
muscles, tendons or ligaments between the ribs (intercostal structures). Rib fractures are
relatively common injuries in athletes, particularly those who compete in contact
sports.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
nerves and the subclavian vessels. Fractures of the first and second ribs may be more
likely to be associated with head and facial injuries than other rib fractures. 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. The most commonly fractured ribs are the 7th and 10th. A
lower rib fracture has the complication of potentially injuring the diaphragm, which could
result in a diaphragmatic hernia.Rib fractures are usually quite painful because the ribs
have to move to allow for breathing. Even a small crack can inflame a tendon and cripple
an arm.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.The chest wall
protects underlying sensitive structures by surrounding internal organs with hard osseous
structures including the ribs, clavicles, sternum, and scapulae. An intact chest wall is
necessary for normal respiration.Rib fractures may compromise ventilation by a variety of
mechanisms. Pain from rib fractures can cause respiratory splinting, resulting in
atelectasis and pneumonia. Multiple contiguous rib fractures (ie, flail chest) interfere with
normal costovertebral and diaphragmatic muscle excursion, potentially causing ventilatory
insufficiency. Fragments of fractured ribs can also act as penetrating objects leading to the
formation of a hemothorax or a pneumothorax. Ribs commonly fracture at the point of
impact or at the posterior angle (structurally their weakest area). Ribs four through nine (4-
9) are the most commonly injured.
Causes

• Direct blow to the chest from a blunt object, such as an arm or elbow.
• Compression of the chest, as when a player falls on his side with a ball or helmet
between him and the ground, or when a player is crushed in a pileup.

• Vehicular accident
Signs & Symptoms

• Severe pain at the fracture site.

• Tenderness to the touch.
• A feeling that the "wind has been knocked out" (sometimes).
• Abdominal pain if the fractured ribs are below the diaphragm (the 11th and 12th
ribs).
• Severe chest pain when coughing, sneezing or breathing deeply.
• A feeling of small air pockets under the skin of the chest or neck if the lung has
been injured and leaked air.
• Swelling and bruising over the fracture site.

Diagnostic Measures

• Your own observation of symptoms.

• Medical history and exam by a doctor.
• X-rays of the ribs and vertebral column. Early may not show fractures if they are not
led, but repeat X-rays taken 4 or more days later usually reveal them. The early
treatment for an uncomplicated rib fracture is
the same as for bruised ribs, so a delay in diagnosis does not hinder treatment.

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 analgesia can
avoid this.Flail chest is a potentially life-threatening injury and will often require a period of
assisted ventilation. Flail chest and first rib fractures are high-energy injuries and should
prompt investigation of damage to underlying viscera (e.g., lung contusion) or remotely
(e.g., C spine injury).Spontaneous fractures in athletes generally requires a cessation of
the cause, e.g., time off rowing, whilst maintaining cardiovascular fitness.

Treatment options for internal fixation/repair of rib fractures include:

• Acute Innovations RibLoc is a titanium U-Shaped plate that is sized to match rib
thickness and uses screws that fixate to anterior and posterior of plate and provide
fixation without needing bone purchase for screws and without risking damage to
 the neurovascular bundle. These plates can be contoured to match the rib segment
being plated and come in various lengths.

• Judet and/or Sanchez Plates/Struts are a metal plate with strips that bend around
the rib and then is further secured with sutures.

• Synthes MatrixRIB Fixation System has two options: a precontoured metal plate
that uses screws to secure the plate to the rib; and/or a intramedullary splint which
is tunneled into the rib and secured with a set screw.

• Anterior locking plate are metal plates that have holes for screws throughout the
plate. The plate is positioned over the rib and screwed into the bone at the desired
position. The plates may be bent to match the contour of the rib section.

Sternal Fracture

It is a fracture of the sternum (the breastbone), located in the center of the chest. The
injury, which occurs in 5–8% of people who experience significant blunt chest trauma, may
occur in vehicle accidents, when the still-moving chest strikes a steering wheel or
dashboard[2] or is injured by a seatbelt.[3] Sternal fracture can interfere with breathing by
making it more painful; however, its primary significance is that it can indicate the presence
of serious associated internal injuries, especially to the heart and lungs.

Causes
Vehicle collisions are the usual cause of sternal fracture; the injury is estimated to
occur in about 3% of auto accidents. the chest of a driver who is not wearing a seat belt
may strike the steering wheel, and the shoulder component of a seatbelt may injure the
chest if it is worn without the lap component. It was common enough for the sternum to be
injured by the seatbelt that it was included in the 'safety belt syndrome', a pattern of
injuries caused by seat belts in vehicle accidents. The injury can also occur when the
chest suddenly flexes, in the absence of an impact.

Signs & Symptoms

• Chest pain

• Bruising and Inflammation

• Deformity and crepitation

• Breathing difficulty
Diagnostic Measures

• X-rays of the chest are taken in people with chest trauma and symptoms of sternal
fractures,

• and these may be followed by CT scanning.

Treatment
Primary treatment is adequate analgesia with nonsteroidal anti-inflammatory drugs
and opiates. Select these on the basis of relative indications and contraindications for each
patient and administer in standard doses and routes. Since sternal fractures can take
weeks to heal, do not hesitate to offer adequate analgesia for this recovery period. No
other pharmacologic therapies are indicated specifically for treatment of sternal fractures.