Treatment of Simple rib fracture includes following EXCEPT
Ans. d. (Strapping of chest) (Ref Bailey and Love 25th/343)Localised rib fracture due to direct trauma. A simple rib fracture may be serious in elderly people or in those with chronic lung disease who have little pulmonary reserve. Uncomplicated fractures require sufficient analgesia to encourage a normal respiratory pattern and effective coughing. Oral analgesia may suffice but intercostal nerve blockade with local anesthesia may be very helpful. Chest strapping or bed rest is no longer advised and early ambulation with vigorous physiotherapy (and oral antibiotics if necessary) is encouraged. A chest radiograph is always taken to exclude an underlying pneumothorax. It is useful to confirm the skeletal injuries but routine chest radiography may miss rib fractures. However, once a pneumothorax and major skeletal injuries are excluded, the management is the same - the local control of chest pain.THE COMPONENTS OF CHEST INJURY IN BLUNT TRAUMAMajor chest wall traumaa. Flail chest: This occurs when several adjacent ribs are fractured in two places either on one side of the chest or either side of the sternum. The flail segment moves paradoxically, that is, inwards during inspiration and outwards during expiration, thereby reducing effective gas exchange. The net result is poor oxygenation from injury to the underlying lung parenchyma and paradoxical movement of the flail segment. This creates a right-to-left shunt and prevents full saturation of arterial blood. In the absence of any other injuries and, if the segment is small and not embarrassing respiration, the patient may be nursed on a high-dependency unit with regular blood gas analysis and good analgesia until the flail segment stabilises. In the more severe case, endotracheal intubation is required with positive pressure ventilation for up to 3 weeks, until the fractures become less mobile. Thoracotomy with fracture fixation is occasionally appropriate if there is an underlying lung injury to be treated at the same time. An anterior flail segment with the sternum moving paradoxically with respiration can be stabilised by internal fixation but operative management is not usual for either.b. First rib fracturec. Fractures of the sternum.d. Vertebraee. Pleuraf. Traumatic pneumothoraxg. Continuing blood loss in excess of 200 mL/hour may require urgent thoracotomy within the first few hours.h. Lung contusion.It is important to prevent infection of the underlying lung by early mobilisation (if the patient's condition permits), prophylactic antibiotics, suction drainage and physiotherapy.MANAGEMENT OF BLUNT CHEST TRAUMAMost chest injuries where the heart is not injured are managed conservatively with underwater seal drainage if necessary, and oxygen and physiotherapy to help the patient to expectorate while the underlying lung parenchyma heals. In about 10 per cent of cases a thoracotomy is required. The indications for thoracotomy following blunt thoracic trauma are the following:# 50--1000 mL of blood at the time of initial drainage is common and may need no further action, but greater volumes, especially if the blood is fresh, require intervention;# continued brisk bleeding (>100 mL/15 minutes) from the intercostal drains indicates a serious breach of the lung parenchyma and urgent exploration is required;# continued bleeding of >200 mL/hour for 3 or more hours may require thoracotomy under controlled conditions;# rupture of the bronchus, aorta, esophagus or diaphragm;# cardiac tamponade (if needle aspiration is unsuccessful).All explorations following trauma should have double-lumen tube endotracheal intubation to facilitate surgery on the injured side and to protect the undamaged lung.
Analgesics
Physiotherapy
Early ambulation
Strapping of chest
Miscellaneous