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5.02 Rib Fracture and Costochondral Separation


Presentation

A patient with an isolated rib fracture or a minor costochondral separation usually has a history of falling on the side of the chest, being struck by a blunt object, coughing violently or leaning over a rigid edge. The initial chest pain may subside, but over the next few hours or days pain increases with movement, interfering with sleep and activity and becoming severe with coughing or deep inspiration. The patient is often worried about having a broken rib, and may have a sensation of bony crepitus or abnormal rib movement. Breath sounds bilaterally should be normal unless there is substantial splinting or a pneumothorax or hemothorax is present. There is point tenderness over the site of the injury and occasionally bony crepitance can be felt.

What to do:

What not to do:

Discussion

Most fractures and separations are treated with immobilization, but ribs are a special problem because patients have to continue breathing. In the presence of severe pain one should consider the use of an intercostal nerve block or injection of the fracture hematoma with 0.5% bupivacaine hydrochloride (Marcaine). Because of the risks of pneumothorax or hemothorax, this procedure, in most cases, should be reserved for secondary management when initial treatment has proven ineffective.

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