it only hurts when I breathe

Monday, September 26, 2011

Trying to figure who hurt what on a Sunday afternoon can be challenge. Injury reports can be less than specific but sometimes too much information can be just as bad. The past week has been filled with discussions in print and online about the woes of Tony Romo, his injured ribs and collapsed lung. How can his body let him perform and play as an NFL quarterback just a week after getting hurt? A couple of questions need to be addressed.

Does playing put Romo’s life at risk?
When a patient presents with a rib injury, the least of the worry is whether there is a fractured rib. It isn’t important whether a rib is broken or just bruised, the treatment will be the same. The diagnostics are aimed not at confirming a broken rib but rather the potential associated complications.

The most common worries are pulmonary contusion or a bruised lung, pneumothorax or collapsed lung and damage to organs in the upper abdomen like the liver or spleen. Physical examination can find where the rib pain is located just by feeling the ribs. Listening to the underlying breath sounds with a stethoscope can help determine whether there is potential lung damage. Examining the abdomen looks for potential damage to the liver and spleen, organs that are located in the upper abdomen and normally protected by the lower ribs. The initial test of choice is a plain chest x-ray looking for lung issues. Broken ribs may or may not be seen.

A collapsed lung can be a big deal or it can be an incidental finding depending upon how much of the lung is collapsed. We breathe like a bellows. Air gets sucked into the lungs when the ribs swing out. Normally, an inflated lung is held up against the chest wall by negative pressure and it needs to slide along the inside of the chest wall with each breath. The pleura is a glistening lining on the surface of the lung and ribcage that allows this to happen. There is a potential space between those two layers of pleura and if air gets into it and breaks the seal, the lung can shrink away from the chest wall and “collapse”. With a rib fracture, the sharp edge of the broken rib can pierce the lung tissue and allow some air to escape into the pleural space. There can be a 100% pneumothorax with total collapse of the lung or there can be a minimal amount that is seen as an incidental finding if a CT scan is done (remember that pro athletes often get over tested).

Treatment depends upon many factors including how well the patient is breathing, how much oxygen is in the blood stream and the size of the pneumothorax. Small collapses can be observed and heal on their own with the air being absorbed naturally by the body. A large pneumothorax may need to be treated with a chest tube, where a small tube placed between the ribs into the chest can suck the air out of the pleural space.

Presumably, Romo’s pneumothorax is insignificant and not an imminent danger, though there is always a possibility that the collapse could recur and be even larger than the original.

How well will Romo play?
Pain is the limiting factor with rib fractures. Each breath causes the broken rib edges to scrape against each other and hurt. Trunk muscles surrounding the chest can go into spasm and every twist and turn can cause significant pain. Often people end up sleeping in recliners because it’s too hard to find a comfortable position and trying to get from lying to sitting to standing is too painful. Pain control allows deep breaths to expand the lung to its fullest and prevent pneumonia, the major complication of rib injury. Ares of lung that don’t get air into them are dark, warm places that are a perfect incubator for infection.

Romo plays safely if his lung is fully expanded. He plays well if his pain can be kept under control so that he is concentrating on the game and not on his breathing. Many artists are willing to suffer for their art. The same goes, it seems, for athletes.

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