65.3 Uncomplicated fractures of the ribs and sternum

Fractured ribs are not important unless many are fractured or unless there are serious injuries inside the patient’s chest. The first three ribs are protected by the shoulder girdle in all but the most serious injuries, so it is usually the middle or lowe ones that break. When many of a patient’s ribs have been broken the organs inside his chest are sure to have been injured also.

X–rays show only about half of the fractures that exist. They are not really necessary, if you are sure there is no pneumothorax, or least not a large one.

If there are no complications, fractures of the ribs need no treatment except for pain. Local anaesthesia properly done especially with bupivacaine (A 6.7), can be very effective in relieving this.

Fracture of the sternum is another steering wheel injury. A patient’s sternum fractures at the junction of its manubrium and body. Or, it can fracture in an acute flexion injury of his spine. Pain is severe and may interfere with breathing. Treatment is straightforward. Lie him flat in bed for 10 days, unless this interferes with breathing.

Sometimes, a patient’s ribs break all round his sternum, so as to produce a ’flail sternum’. This is merely a variety of flail chest.

BROKEN RIBS AFTER A CHEST INJURY

LOCAL ANAESTHESIA FOR BROKEN RIBS Carefully feel the tender areas that indicate the patient’s fractures. Mark them on his skin. Inject each fractured rib with 3 ml of 1.5% bupivacaine, or 1% lignocaine, making sure the tip of the needle is down on the rib in the subperiosteal space close to the fracture site. Often, pain relief lasts days, much longer than would be expected after a single dose of anaesthetic solution. The patient will be very grateful.

Figure 65.7: HAEMOPNEUMOTHORAX. A, when you examine for a haemothorax, slide your stethscope under the patient while he is lying down, and listen for reduced air entry. B, this patient’s lung has collapsed and he has a fluid level in his pleural cavity. C, if you drain a haemopneumothorax with a single tube, cut side holes in it and push it well up inside the pleural cavity. Kindly contributed by James Cairns and Peter Bewes.

MANAGEMENT depends on how many ribs are broken and where they are broken.

If only a few of a patient’s ribs are broken, (less than 4 fractures are visible on an X–ray, if you take one), and if there are no pulmonary signs, management depends on his age and activity. If he is young, treat him as an out–patient.

The main risk is infection in the underlying injured lung, especially in a frail old person, and particularly in a heavy smoker, who is not physically active. Keep him moving, give him analgesics, and encourage deep breathing exercises. Warn him that pain may take 3 months to go away.

If a patient’s sternum is fractured, lie him flat in bed for a few days, unless this interferes with his breathing.

If he has signs of a haemothorax or pneumothorax, admit him.

If his lower ribs are broken, consider the possibility of a rupture of his liver (66.7) or spleen (66.6).