Anatomy Msk · Year 1 · from Anatomy Msk
Case 1: Rib Fractures with Pulmonary Contusion
Clinical Image
Source: Wikimedia Commons - Rib Fractures - CC BY-SA 3.0
Case Presentation
A 45-year-old construction worker is brought to the emergency department after a fall from a ladder, landing on his right side against scaffolding. He reports severe right-sided chest pain that worsens with deep breathing, coughing, and movement. He is slightly short of breath. Physical examination reveals tenderness and crepitus over the right lateral chest wall at ribs 6-9. There is splinting with shallow respirations. Oxygen saturation is 94% on room air. Auscultation reveals decreased breath sounds at the right lung base. Chest radiograph demonstrates fractures of right ribs 6, 7, 8, and 9 along the axillary line, with a small right hemothorax and patchy opacity in the right lower lung consistent with pulmonary contusion. CT chest confirms multiple rib fractures, a small hemothorax (150 mL), and pulmonary contusion without evidence of pneumothorax or great vessel injury. He is admitted for pain control with patient-controlled analgesia and intercostal nerve blocks, incentive spirometry, and respiratory monitoring. Serial chest X-rays show no progression of hemothorax, and he is discharged after 3 days with oral analgesics and instructions for follow-up.
Key Learning Points
- Ribs are curved flat bones; fractures typically occur at the weakest point (angle of the rib posteriorly)
- Multiple rib fractures (3 or more) are associated with significant pulmonary morbidity
- Ribs protect thoracic organs but fractures of lower ribs (9-12) should prompt evaluation for hepatic/splenic injury
- Adequate pain control is essential to allow deep breathing, coughing, and prevent atelectasis and pneumonia
- Intercostal neurovascular bundle (VAN: vein, artery, nerve) runs inferior to each rib - chest tubes placed above rib