imagining rib injuries: CT…really?…not

Wednesday, August 17, 2016

The availability of medical technology in the 21st century has a tendency for patients to demand its use, regardless of whether the information it can reveal actually matters. Nothing better highlights this issue than the overuse of radiology by pro sports. This week’s prime example is Carson Wentz, Philadelphia’s first round rookie quarterback, and leader of the future. Towards the end of the game against Tampa Bay, Wentz is hit on the right side and has pain in his right ribs. quoted Eagle coach, Doug Pederson: “Carson felt some discomfort and soreness as we began this morning’s practice. We decided to limit him throughout the remainder of practice and, as a precaution, sent him for a CT scan after practice. The scan revealed a hairline fracture in his ribs.We do not know an exact timetable for his return, but we hope to have him back before the end of the preseason.”

FYI: fracture, broken, cracked all mean the same thing

Perhaps the CT seems like a reasonable care plan, with the coach and the team worried about their player, but in reality, this is not the standard of care that most people would receive. In the real world, people who hurt their ribs are often examined and may or may not get a simple chest x-ray. CT is definitely not routine.

Here is the thinking. The chest wall, rib cage and muscles have a couple of important jobs. The first is to protect the contents of the chest cavity (thorax) including the heart, lungs and great vessels (aorta, vena cava among others), as well as organs in the upper abdomen like the spleen and liver. The second, is the muscles of the chest wall and the diaphragm that are responsible for the work of breathing. When taking a deep breath, the ribs swing out, the diaphragm pushes down and air is sucked into the lungs like a bellows.

If the rib cage is injured, pain may prevent that process from working well. Deep breaths don’t occur and a multi-step process ends up in the complication of pneumonia. It doesn’t matter whether ribs are bruised or broken, it’s a matter of the pain that causes the problem:

  • Pain decreases the ability to take a deep breath
  • Without that deep breath, the alveoli, small sacs at the end of the bronchial tree, where oxygen gets transferred to the blood stream, can’t pop open. This is called atelectasis
  • With atelectasis, the lungs can’t clear normal secretions and debris and the gunk is left to accumulate in the warm, dark environment. This increases the risk of lung infection
  • A lung infection is called pneumonia and the symptoms include, fever, cough and shortness of breath.
  • Pneumonia associated with chest injury is not a good combination because it becomes that much tougher to take a deep breath to help clear the infection. This failure of pulmonary toilet increases the risk of complications.

While rib injuries hurt, the bigger concern is not the pain but whether damage occurred beneath the injured ribs. If that suspicion is low and physical exam does not point to disaster, then the test of choice is a simple chest x-ray, looking for a collapsed lung (pneumothorax) or a bruised lung (pulmonary contusion). Specific rib x-rays aren’t needed and a CT of the chest to look for rib fractures is definitely overkill.

chest ct rib fx

Black arrow points to rib fracture. White arrows show collapsed lung. Plain X-ray might miss the fracture but not the pneumothorax.

Regardless of whether the rib cage is bruised or a rib is broken, the treatment is the same: pain control and deep breaths to prevent atelectasis and pneumonia and the healing time is 4 to 6 weeks. Just like any other broken bone or torn muscle, it takes that long to get better. Chest injuries may take longer, since the area that is damaged is not allowed to rest and heal. A sore arm can be put into a sling to rest, but a sore chest is asked to work every few seconds, mandating a deep breath to prevent pneumonia.

While NFL coaches can’t order CT scans, team doctors can sign off on that request, and the rationale is presumably to make certain nothing terrible was hiding inside Mr. Wentz’ chest. Aside from increasing his lifetime accumulation of radiation exposure, there would be little risk for the test but also very little reward. Perhaps the major issue will occur later, when fans who see an NFL player gets a CT scan for a chest wall injury, will demand their share of high tech medicine, when low tech might do just as well.

It’s the part of the doctor’s job to explain what tests are needed, and what the next steps are once those results are back. In this regard, doctors and patients can learn from an NFL coach. There always needs to be a game plan for whatever situation might arise on the field. Similarly, there needs to be a game plan based on the history, physical exam and whatever the test results might show. And while Coach/Dr. Pederson may order a CT as a precaution, that shouldn’t necessarily fit into most people’s game plans. Just because there is a test that can be done, doesn’t mean that it is the right thing to do.

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agony of defeat…tib fib fractures

Sunday, August 7, 2016

The public seems to have a morbid curiosity about trauma. While major injury makes us turn way and not want to look when an athlete gets hurt, it’s that same injury that gets millions of view on Twitter and YouTube. Tib-fib fractures seem to be immensely fascinating, given the long term popularity of Joe Theismann’s broken, injured while playing for the Redskins in 1985.

French gymnast, Samir Ait Said, suffered the same injury during the vault in Rio. A collective groan could be heard in the arena, as could the snap of the bones…and the clicks making him trend on Twitter.

tibfib fracture

  • The initial injury may seem gruesome, but it is the potential complications that may be even worse. This is especially true for tibia and fibula fractures, similar to Thiesmann’s and Said’s. The skin overlying the shin is very thin and with the force of the injury, it is not uncommon for the overlying skin to be cut, torn, lacerated…choose a word. The old term “compound” has been replaced with “open” which describes the fact that the inside of the bone is now exposed to the outside world and the risk of bone infection increases dramatically.
  • The muscles that surround the tibia and fibula are encased in four tight compartments and with an injury like a broken leg, bleeding and swelling can increase the pressure within one, many or all of the compartments. If the pressure inside a compartment increases higher than venous pressure, blood cannot flow back to the heart and swelling starts to occur, increasing the pressure even further. If the pressure is not released by fileting open the compartment, muscle and nerve tissue dies and badness ensues. Up to 10 percent of midshaft tibia fractures may have an associated compartment injury.
  • Other complications that can occur in the next few days include nerve damage, (the peroneal nerve is often the target when the fibular head is damaged and leads to foot drop), skin sloughing because of poor blood supply to the front of the shin, and leg amputation if the fracture repair is delayed. Because both bones are broken, the leg is unstable and can flop around if not immobilized. This can stretch or tear the arteries that are heading to the ankle and foot causing loss of blood supply, a bad thing. Knee dislocations are associated with artery injury and often, the diagnosis may be initially missed because the knee often relocates before it is evaluated by medical personnel.
  • And long term, non-union of the fracture may occur. The tibia is the most common bone to refuse to heal, leading to repeated surgeries. It’s all about get blood supply to the area of injury, so that the body can deliver the building blocks needed to reconstruct the bone. This is a design flaw of the body that leads to poor blood supply and poor healing. Unfortunately, it’s not the only place where the body was not engineered to supply blood to broken bones. Scaphoid fractures in the wrist are another example.

BBC Gets It Right

While Mr. Said lay on the ground, attended by trainers and doctors, the internet started to exploit the injury, giving those who have a fascination with pain and suffering the opportunity to watch replays of the injury. Twitter, YouTube,Facebook and numerous news websites posted videos and photos of the injury. While NBC’s website displays a warning about graphic images, perhaps BBC understands that most people do not want to be “entertained” by such misery. Their reporting ends with the following:

“Highlights footage and photos of the injury are too graphic to be shown on the BBC Sport website.”

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