10. Rib fractures

4th or 5th intercostal space and a chest retractor is inserted. After the bleeding is controlled and a steady heartbeat has been achieved, the patient must be transferred to the operating room as

Subcutaneous emphysema develops as a result of the entry of air into the subcutaneous soft tissue of the thoracic wall. Characteristic crepitations are felt during palpation, while diagnosis can be made through a visualization of air in the subcutaneous tissue and between the muscles in a lung radiography. The amount of skin emphysema depends on the amount of air leakage from the lungs. While only skin crepitations are present in mild cases, advanced subcutaneous emphysema can be seen when there is intense air leakage and a large defect in the parietal pleura. These cases may present with swelling of the head, neck and face, and while there is no specific treatment for subcutaneous emphysema, the underlying factor should be eliminated. To reduce subcutaneous emphysema, air drainage can be performed by injecting a few largelumen wide-diameter granules subcutaneously and between the muscles of the anterior tho-

soon as possible [36].

104 Trauma Surgery

8. Subcutaneous emphysema

racic wall (Figure 3) [31, 32].

9. Contusion and hematoma of the thoracic wall

The thoracic wall is supplied by the internal thoracic artery, which originates directly from the aorta and branches to the intercostal arteries before spreading to all ribs along both sides of the

Figure 3. Thorax CT image of a patient with common subcutaneous emphysema that results from a blunt thorax trauma.

The most common type of injury, and one encountered in approximately 35–40% of all thoracic trauma cases, is rib fracture. Rib fractures are more frequent in the elderly due to the decreased elasticity of the thoracic wall. An anterior trauma to the thoracic wall generally results in rib fracture from the outer surface, while lateral traumas cause internal rib fractures. Rib fractures are mostly encountered along 4–9 and the middle axillary line, while fractures of the first and second ribs are generally rare, as these are supported by the clavicle, scapula and shoulders. That said, these ribs may be broken due to very high-energy trauma, and fractures of this kind may well be accompanied by subclavian vessel and brachial plexus injuries. It should be highlighted that rib fractures may be accompanied by lung, bronchus or cardiac injuries. Additionally, abdominal organ injuries, such as the liver and spleen, may occur in the presence of 9th–12th rib fractures, while trauma to the anterior thoracic wall may result in costochondral detachment, which is a more painful condition that requires a longer duration of treatment [22, 26, 31].

Painful tenderness is the most important symptom in the event of rib fracture, and the symptom generally increases with coughing, deep breathing and movement. Friction between the broken rib ends may be felt during a physical examination. Almost half of all rib fractures go unnoticed in lung radiographies, while thoracic CT is more specific for their diagnosis [22, 26]. The treatment of rib fractures is based on pain control and respiration exercises. Pulmonary rehabilitation, including respiration exercises, is crucial in preventing pain-induced secretions, lack of expectoration, atelectasis and pneumonia. Early-term complications of rib fractures include pneumothorax and hemothorax, and late-term complications include atelectasis and pneumonia. A tube thoracostomy is inevitable in the presence of hemothorax and pneumothorax, and surgical fixation becomes necessary when the fractured tips are displaced, and when there are fractures to more than one consecutive rib. Morbidity and mortality in rib fractures depend on the age of the patient, the number and localization of the fractured ribs, and the degree of the concomitant trauma (Figure 4) [6, 31, 37].
