2 English references rib fracture [Chinese medicine terminology Committee. Terminology of Traditional Chinese Medicine (2004)]
3 Summary Rib fracture (1) refers to a disease characterized by local slight swelling and pain of ribs, which is aggravated when taking a deep breath, coughing or sneezing, or even bending over, and has obvious local tenderness [1]. Rib fracture accounts for about 6 1% ~ 90% of chest injury.
The pathological characteristics of rib fracture caused by different external violence can have different characteristics: direct violence on limited parts of the chest causes rib fracture, and the broken end moves inward, which can puncture intercostal blood vessels, pleura and lung, resulting in hemothorax or (and) pneumothorax. Indirect violence, such as chest compression, fractures are mostly in the middle of ribs, and the broken ends shift outward, stabbing the soft tissue of the chest wall and producing chest wall hematoma. Rib fractures caused by gunshot wounds or shrapnel injuries are often comminuted fractures. In children, ribs are elastic and not easy to break, while in adults, especially the elderly, ribs are weak and easy to break.
The diagnosis of rib fracture is mainly based on the history of trauma, clinical manifestations and chest X-ray examination. Pressing the non-fractured part of the sternum or rib (chest pressure test) causes pain (indirect tenderness) at the fractured part, or directly pressing the fractured part of the rib causes direct tenderness, or bone rubbing sound can be heard and felt at the same time, which is of great diagnostic value. Most rib fractures can be shown on X-ray chest films. However, rib cartilage fracture, "willow branch fracture", fracture without dislocation, or intercostal fracture are not easy to find on chest radiograph because of the overlapping ribs on both sides, and should be judged according to clinical manifestations to avoid missed diagnosis. A rib fracture without injury is called a simple rib fracture. In addition to pleural and lung injuries and hemothorax or pneumothorax caused by them, there are often other chest injuries or chest injuries, which should be paid special attention to in diagnosis. 1 or fracture of the second rib is often accompanied by clavicle or scapula fracture, which may be accompanied by injury of internal organs and great vessels in the chest, rupture of bronchus or trachea, or cardiac contusion, often accompanied by brain injury; Lower thoracic rib fracture may be complicated with visceral injury, especially rupture of liver, spleen and kidney, and fracture of spine and pelvis should also be paid attention to. However, when the rib below the seventh rib is fractured, the intercostal nerve at the fracture site appears conductive abdominal pain, which should be distinguished from the indicative abdominal pain caused by abdominal organ injury.
6 treatment measures The treatment principle of simple rib fracture is to relieve pain, fix and prevent lung infection. If necessary, analgesic can be given orally or intramuscularly. Intercostal nerve block or pain point block has good analgesic effect and can improve breathing and effective cough function. During intercostal nerve block, 5ml of 0.5% or 1% procaine can be injected into the lower edge of the broken bone 5 cm beside the spine, and the injection range includes 1 rib above the broken bone and 1 rib below the broken bone. Pain point sealing is to inject procaine directly into the rib fracture, each 10 ml. If necessary, block or block 12 ~ 24 hours repeatedly, or use long-acting painkillers. Be careful not to puncture too deep, so as not to puncture the pleura. Semi-circular adhesive tape fixation can stabilize fractures and relieve pain. The method is to use several pieces of adhesive tapes with a width of 5-7 cm, and stick them on the chest wall from back to front and from bottom to top, overlapping each other by 2-3 cm, with both ends exceeding the front and back midline by 3 cm, including one rib above and below the fractured rib (Figure 5-3). However, due to its unsatisfactory analgesic effect, limited breathing, skin allergy and other complications, it is generally not used unless it is considered to transfer the wounded, or it is better to use multi-head chest strap or elastic chest strap. The prevention of pulmonary complications mainly lies in encouraging patients to cough, often sitting up and assisting in expectoration, and suctioning sputum in trachea when necessary. Give antibiotics and expectorants in moderation.
In addition to the above principles, special attention should also be paid to eliminating abnormal breathing movements as soon as possible, keeping the respiratory tract unobstructed and fully supplied with oxygen, correcting respiratory and circulatory disorders and preventing shock. When the softening range of chest wall is small or located on the back, the abnormal breathing movement may not be obvious or serious, and local pad pressure dressing can be used. However, when the floating range exceeds 3 cm, it can cause serious respiratory and circulatory dysfunction, and when it exceeds 5 cm or bilateral flail chest (soft chest syndrome), it can quickly lead to death, so emergency treatment must be carried out. First, use the clamp pad to temporarily press and bind, and then pull and fix the ribs. In the past, towel tongs were usually used for gravity traction. The method is to forcibly select 1 ~ 2 ribs in the center of the floating chest wall. After local anesthesia, stab a small mouth with a sharp knife at the upper and lower edges respectively, and clamp the ribs with cloth tongs, taking care not to damage intercostal blood vessels and pleura. The tail of the tongs is tied with a traction rope and pulled with a pulley for about 2 weeks. At present, a variety of tractors are designed according to similar principles, in which a special hook is used to replace the towel clip, and a traction frame fixed outside the chest wall is used to replace the pulley gravity traction. The method is simple and convenient, and the patient can get up and move, which is convenient for transfer (Figure 5-4). For patients who need thoracotomy, rib fracture can be fixed by stainless steel wire binding suture or intramedullary fixation with kirschner wire. At present, it is not recommended to use controlled mechanical ventilation to eliminate abnormal respiratory movement (respiratory internal fixation) in flail chest patients, but it is still very important to treat patients with severe lung contusion and acute respiratory failure with tracheal intubation or ventilator in time after tracheotomy.
Most rib fractures can heal spontaneously within 2 ~ 4 weeks, and the treatment does not emphasize the joint of broken ends like limb fractures. A simple rib fracture itself is not fatal. The focus of treatment is the management of flail chest, the treatment of various combined injuries and the prevention and treatment of complications, especially respiratory failure and shock.
Clinical manifestations Occasionally, due to severe coughing or sneezing, the chest muscles suddenly contract strongly, causing rib fractures, which are called spontaneous rib fractures, and most of them occur in the sixth to ninth ribs under the armpit. When the rib itself is diseased, such as primary tumor or metastatic tumor, rib fracture can also occur with little or no external force, which is called pathological rib fracture.
Rib fractures mostly occur in the 4 th to 7 th ribs; Rib 1 ~ 3 is protected by clavicle, scapula and shoulder strap muscles and is not easy to break; The 8th ~10 rib gradually becomes shorter, connecting the cartilaginous costal arch, which has elastic cushioning and reduces the chance of fracture. Ribs 1 1 and 12 are floating ribs, with high fluidity and few fractures. However, when the violence is strong, these ribs may be broken.
Only a 1 rib fracture is called a single rib fracture. Two or more rib fractures are called multiple rib fractures. Rib fractures can occur in both chests at the same time. Only one fracture of each rib is called a single fracture, and more than two fractures are called double fractures or multiple fractures. Sequential multiple rib fractures or multiple rib fractures combined with multiple costal cartilage epiphyseal detachment or bilateral multiple costal cartilage fractures or epiphyseal detachment will cause chest wall softening, which is called chest wall floating injury, also known as flail chest.
Local pain is the most obvious symptom of rib fracture, which is aggravated with coughing, deep breathing or body rotation. Sometimes patients can hear or feel the "bang" bone friction at the rib fracture. Pain and impaired thoracic stability can limit breathing activities, make breathing shallow and fast, and reduce alveolar ventilation. Patients dare not cough, sputum retention, resulting in lower respiratory tract secretion obstruction, lung dampness or atelectasis. This should be paid more attention to in elderly and frail patients or patients with original lung diseases. Flail chest, the negative pressure of chest cavity increases when inhaling, and the softened part of chest wall is depressed inward; When exhaling, the chest pressure increases and the injured chest wall floats and protrudes, which is contrary to the movement of other chest walls and is called "abnormal breathing movement". Abnormal respiratory movement can make the pressure on both sides of the chest unbalanced, and the mediastinum moves back and forth with breathing, which is called "mediastinal swing", which affects blood return and causes circulatory dysfunction, and is one of the important factors that lead to and aggravate shock. Flail chest pain and chest stability damage are more serious. Abnormal respiratory movement makes respiratory movement more limited, cough is weak, vital capacity and functional residual capacity (FRC) decrease, lung compliance and tidal volume decrease, often accompanied by severe dyspnea and hypoxemia. In the past, it was thought that part of the gas in the flail chest flowed back and forth between the healthy side and the injured side with inhalation and exhalation, and could not be exchanged with the atmosphere, which was called residual gas convection or swinging gas, which was the main cause of respiratory dysfunction. However, at present, it is considered that oscillatory gas does not exist, and lung contusion often accompanied by flail chest can cause alveolar and interstitial bleeding, edema, alveolar rupture and atelectasis, which is an important cause of respiratory dysfunction.
8 complications