2. Dr. Muhammad Younus MBBS, MCPS, FCPS (Pulmonology)

3. Rib Fractures

4. Anatomy

5. Anterior Thoracic Landmarks
Suprasternal Notch – U shaped depression
Sternum – “breastbone” = 3 parts
Manubrium
Body
Xiphoid process
Angle of Louis – manubriosternal angle continuous with the 2nd Rib
Costal angle- usually 900 or <. (increases when rib cage is chronically overinflated)

7. Posterior Thoracic Landmarks
Vertebra Prominens – Flex head, feel most prominent bony projection at base of neck = C7 next lower one is T1
Spinous Processes – spinal column-
Scapula – symmetrical , lower tip at the 7 -8th Rib
12th Rib = midway b/t spine & side

9. Ribs 12 pairs of ribs 7 true ribs
5 false ribs (including 2 floating ribs)
Head of rib articulates with vertebra
Ribs move as a unit to accommodate breathing
Intercostal spaces =
(spaces between ribs)

10. False and Floating Ribs
All 12 pairs of ribs attach to the building blocks of the spine (vertebrae) in the back. The 12 pairs of ribs consist of:
True ribs: The first seven ribs attach to the sternum (the breast bone) in the front and are known as true (or sternal) ribs.
False ribs: The lower five ribs do not directly connect to the sternum and are known as false ribs.
The upper three false ribs connect to the costal cartilages of the ribs just above them. The last two (#11 and 12) are false ribs. They have no ventral attachment (no anchor at all in front) and are called floating ribs.

12. Cervical Rib Supernumerary (Extra) Rib present above the 1st rib
Arises from 7th cervical vertebra
Present in 1 in 500 peoples
Can cause thoracic outlet syndrome due to compression on the brachial plexus and subclavian artery.

18. Rib Fractures Trauma is the most important cause of rib fractures
First Rib : Rare , associated with cranial, maxillofacial ,cervical spinal injuries , multiple rib fractures and life threatening vascular injuries.
Second, Third and fourth : Associated with major vascular injuries and injury to brachial plexus.

19. Rib Fractures
Fifth to Ninth ribs : can be single or multiple. Multiple fractures can present as flail chest, which is present when paradoxical respiratory movement occurs in a segment of the chest wall.
This type of fracture requires at least 2 segmental fractures in each of 3 adjacent ribs, the costal cartilages, or the sternum

20. Rib Fractures
Tenth to twelfth ribs : Associated with thoracic and lumber vertebral injuries
Injuries to spleen , kidneys adrenals , liver may occur.

21. Rib Fractures
Pathological Rib Fractures: occurs spontaneously without trauma due to weakness of the bone by the underlying disease.
- Metastasis
- Multiple myeloma
- Hyperparathyroidism

23. Complications Pulmonary contusion (almost always)
Airspace disease representing hemorrhage into the alveoli usually subjacent to the point of impact
Pulmonary laceration
Lacerations in the lung may be blood-containing, air-containing, or both
Frequently masked by the surrounding pulmonary contusion
Pneumothorax (very common)
Since the severity of the injury means a supine radiograph will be performed, pneumothoraces may only be seen on chest CT
Hemothorax (common)
Pneumomediastinum
Subcutaneous emphysema
Mediastinal hemorrhage
Aortic injuries

24. Flail chest
Flail chest is traditionally described as the paradoxical movement of a segment of chest wall caused by fractures of 3 or more ribs anteriorly and posteriorly within each rib.
Variations include posterior flail segments, anterior flail segments, and flail including the sternum with ribs on both sides of the thoracic cage fractured.
Severe blunt trauma

27. Sternum breastbone Lies in anterior midline of thorax Three parts:
Manubrium
Body
Xiphoid process
Surface landmarks
Jugular notch
Sternal angle ( angle of Louis)

28. Manubrium Broad, upper part of the sternum
Quadrangular shape, wider superiorly and narrower inferiorly
Articulates with the clavicles and the first two ribs.

29. Manubrialsternal Joint
A ridge where the manubrium and the body of the sternum meet
Raised horizontal ridge located at the second rib joint

30. Xiphoid Process Xiphoid means “sword-shaped” May be bone or cartilage
Apex of thoracic arch
“Pit” of stomach, where heartburn often occurs

31. Sternal Fractures Blunt trauma to chest Rarely may occur during CPR
Stress fractures weight lifters , golfers
Long term steroids, severe kyphosis
Fractures usually occurs at body or manubrium
X-Rays Chest PA & Lateral Views , USG Chest
CT chest.

34. Normal chest

35. Pectus excavatum
Most common congenital deformity of anterior chest wall.
Also called funnel chest , sunken chest, cobblers chest.
Lower end of sternum is depressed alongwith costal cartilages.
Treatment is surgical repair.

37. Pectus Excavatum (Funnel)

38. Barrel Shape chest
AP diameter is equal or more than transverse diameter.
COPD

39. Barrel Chest

40. Pectus Carinatum Also called pigeon chest.
Characterized by protrusion of sternum and ribs
Congenital, Obstructive airway disease, Marfan syndrome, turner syndrome, Ehlers danlos syndrome.
Treatment is external braces or surgical.

41. Pectus Carinatum (Pigeon)

42. Sternal defects Very rare
Sternal defects can be categorized into 4 types,:
thoracic ectopia cordis
cervical ectopia cordis
thoracoabdominal ectopia cordis
cleft sternum.
Sternal foramina – perforation in sternal body clinically insignificant.
Perforation of xiphoid process in elderly.

43. Sternal Biopsy
Often used for bone marrow needle biopsy because of its breadth and subcutaneous position
Commonly used for specimen for bone marrow transplant and for the detection of metastatic cancers and blood dyscrasias .

44. Reference Lines Anterior Chest Posterior Chest Midsternal line
Midclavicular line
Posterior Chest
Vertebral line – midspinal
Scapular line

45. Lateral Chest Anterior Axillary line Posterior Axillary line
Mid–axillary line

49. Thoracotomy Surgical creation of an opening through the thoracic wall
Types :
- Anterior thoracotomy
- Posterolateral thoracotomy
- Anterolateral thoracotomy
Posterolateral thoracotomy is the most commonly used site.

50. Median sternotomy Sternal splitting for the mediastinal operations
For upper lobe lung tumours
CABAG
After surgery the halves of sternum are joined using wire sutures.

54. Indications of thoracotomy
Atelectasis, the permanent collapse of lung tissue
Benign (non-cancerous) tumors or cysts
Confirmation of a diagnosis, such as for lung disease
Diaphragm disorders
Diseased or damaged blood vessels of the heart or lungs
Empyema, or infection in the chest cavity
Heart disease
Hemothorax, or blood in the lungs
Lung damage caused by emphysema or bronchietasis
Pleurodesis, a procedure to treat a buildup of fluid in the chest cavity
Pneumothorax, or injuries that cause the collapse of lung tissue
Pulmonary embolism, or a blood clot in the lungs or pulmonary artery
Severe and very specific types of chest injury or trauma, such as certain types of stabbings or gunshot wounds 
Some types of cancer including lung cancer
Trachea (windpipe) or esophageal (swallowing tube) conditions

55. Bone Grafting
A bone graft is surgery to place new bone or bone substitutes into spaces around a broken bone or bone defects.
If the transplanted bone comes from another person, it is called an allograft.
 If the transplanted bone comes from another part of your own body, it is called an autograft. 

56. THANK YOU