Management of Multiple and

Segmental Rib Fractures

Thoracic and Cardiovascular Surgery

Dr. Soetomo’s General Hospital
Medical Faculty of Airlangga University
- Every four trauma, one is thoracic trauma
- Mortality 10%  majority in Hospital
- 12,000 annually in US
- Operation : - blunt trauma  < 10%
- penetrating trauma 15 – 30%
 Thoracic Trauma with the other

- USA : 372 Cases / year

27% extremity injury
15% brain injury
24% digestive tract injury
- Dr. Soetomo’s Hospital Surabaya ( tahun 2006 ) :
203 Cases / year
24% extrimity injury
20% brain injury
9% digestive tract injury
 ANATOMY
Thoracic Cavity :
- Rib
- vertebrae
- sternum
- diafragma
- muscle
 ANATOMY
Anterior :
• OS. Sternum
• OS. Costae
• M. pectoralis mayor
• M. pectoralis minor
• M. obliqus externus
• M. serratus anterior
• M. intercostalis
• M. transversus thoracis
• Lateral :
Os. Scapula , M.intercostalis
• Posterior
- Os. Scapula
- Col. Vertebralis
- M. trapezius
- M. latissimus dorsi
- M. rhomboideus
- M. intercostalis
- M. serratus posterior
Physiology
aktive
of
Respiration
active - inspiration pasive
pasive - expiration

Process of
Respiration:
Ventilation
Distribution
Diffussion
Perfusion
 The Process of Respiration

DISTRIBUTION
VENTILATION

DIFFFUSION
PERFUSION
Ventilation without PERFUSION Perfusion without VENTILATION
 Pathophysiology of Thoracic Trauma

• Ventilation failure
• Gas Transfer / diffusion failure
• Circulation failure
• Hypoxic hypoperfusion of the tissue / celluler
 cytokine  SIRS MODS MOF
Splanchnic Hypoperfusion  bacteri/endotoxin
translocation to systematical circulation.
 Common Division of Thoracic Trauma

• Emergency : - Life Threatening

- Potentially life threatening

• Type of trauma : - Blunt Trauma

- Penetrating Trauma
 Blunt Trauma
The Mechanism of Blunt trauma :
- Stress
- Compression
- Stretching
 Effect of Blunt Trauma

• Rib Fracture
• flail chest
• Sternum fracture
• Lung Contusion
• Pneumotorax
• Hematotorax
• Bronchus rupture
• Hematopericardium  Heart tamponade
 Rib fracture
• Simple
• Multiple
• Multiple and Segmental
Rib Fracture
Consider : -The amount of rib fracture
- location
- complication

Diagnostic : - physic
- radiologic
• Rib Fractures
– >50% of significant chest trauma cases due to
blunt trauma
– Compressional forces flex and fracture ribs at
weakest points
– Ribs 1-3 requires great force to fracture
• Possible underlying lung injury
– Ribs 4-9 are most commonly fractured
– Ribs 9-12 less likely to be fractured
• Transmit energy of trauma to internal organs
• If fractured, suspect liver and spleen injury
– Hypoventilation is COMMON due to PAIN
Management

- Oxigenation
- Relief the pain : - analgesic
- local / block anestesi
- Observe the complication because of
rib fracture, especially multiple rib
fractures
 The site of local
anestesi punction
Multiple and Segmental Rib Fracture
• Flail Chest
– Segment of the chest that becomes free to move with the
pressure changes of respiration
– Three or more adjacent rib fracture in two or more places
– Serious chest wall injury with underlying pulmonary injury
• Reduces volume of respiration
• Adds to increased mortality
– Paradoxical flail segment movement
– Positive pressure ventilation can restore tidal volume
Complication of Multiple Ribs Fracture

• Pneumothorax
• Hematothorax
• Lung contusion
Pneumothorax
• Open Pneumothorax
– Free passage of air between atmosphere and
pleural space
– Air replaces lung tissue
– Mediastinum shifts to uninjured side
– Air will be drawn through wound if wound is 2/3
diameter of the trachea or larger
– Signs & Symptoms
• Penetrating chest trauma
• Sucking chest wound
• Frothy blood at wound site
• Severe Dyspnea
• Hypovolemia
• Tension Pneumothorax
– Buildup of air under pressure in the thorax.
– Excessive pressure reduces effectiveness of
respiration
– Air is unable to escape from inside the pleural
space
– Progression of Simple or Open Pneumothorax
Hematothorax
– Accumulation of blood in the pleural space
– Serious hemorrhage may accumulate 1,500 mL
of blood
• Mortality rate of 75%
• Each side of thorax may hold up to 3,000 mL
– Blood loss in thorax causes a decrease in tidal
volume
• Ventilation/Perfusion Mismatch & Shock
– Typically accompanies pneumothorax
• Hemopneumothorax
Pulmonary Contusion
– Soft tissue contusion of the lung
– 30-75% of patients with significant blunt chest trauma
– Frequently associated with rib fracture
– Typical MOI
• Deceleration
– Chest impact on steering wheel
• Bullet Cavitation
– High velocity ammunition
– Microhemorrhage may account for 1- 1 ½ L of blood loss in
alveolar tissue
• Progressive deterioration of ventilatory status
– Hemoptysis typically present
 Management Of
Multiple Rib Fracture
• Conservative
• Definitive
 Definitive Management

- Plate & screw

- Wire
- Clips / staples
 1

3a 3b
SHAPP KLIP
1 2

3 4
SHAPP KLIP INSTRUMENT
Post Operative Management
Criteria of Removing Chest Tube
• Clinical
• Kuantitative
• Kualitative
• Radiologic