chest wall injuries

Monday, March 18, 2013

There is a great regional rivalry when it comes to barbeque and which style makes ribs taste better. Is it the marinated Memphis, the Kansas City rub, the Carolina vinegar or the plain smoke of Texas? Regardless, we rarely think of the meat we eat as the muscles that help animals, including us humans, breathe. For those who have bruised or broken rib, or like David Wright of the Mets, pulled a rib muscle, it is an injury that is hard to ignore and harder to fix. After injuring an intercostal muscle, Mr. wright couldn’t play for the US national baseball team and returned to spring training to try to mend before the start of the baseball season.

Intercostal muscles are those that are attached to and located between the ribs and are responsible for moving the chest wall during breathing.  We breathe like a bellows with the ribs swinging out and the diaphragm (the muscle that divides the chest and abdomen) pushing down, sucking air into the lungs. Exhaling reverses the process and air is pushed out of the lungs. There are three layers of intercostal muscles that do the work of the rib movement, the external intercostal, the internal intercostals and the innermost intercostals, share the work of breathing and any injury to these muscles affects the ability of air to get into and out of the lungs. The muscle is often injured with a twisting motion; imagine a batter swinging while at bat, or lunging for a line drive in the field. But the injury can also be due to a direct blow, where the ribs don’t break but the muscle take the brunt of the injury.

Muscles don’t like to be hurt and when injured, go into spasm to protect themselves. The diagnosis is usually pretty easy. The patient often knows that they fell or twisted with immediate onset of pain. Sometimes, though the mechanism of injury is a little tougher to find and may be as simple as an aggressive cough or sneeze. Often a chest x-ray is done and not to look for broken ribs. Instead, the most important consideration is the under lying lung. Did the injury cause a collapsed lung (pneumothorax) or a pulmonary contusion (bruise)? It isn’t worth the extra x-rays and radiation to look for a broken rib, since it doesn’t affect treatment.

Chest wall pain, whether it is from the rib or intercostal muscle causes the body not to want to take a deep breath. It hurts too much and the body isn’t stupid. This is not necessarily a good thing when it comes to the ability to breathe. Failure to take a deep breath prevents the lung from fully expanding and those dark and warm crevices are prime breeding grounds for infection, leading to pneumonia. For that reason, treatment is focused on pain control and deep breaths. This plan, however, delays healing, trading length of recovery for pneumonia prevention.

Normally when a muscle is injured, the treatment is rest, ice and compression, allowing the damage to heal. Hurt your arm and a sling is prescribed. Hurt your leg and you get crutches. But the opposite treatment is recommended for the chest wall injury and with every breath the injured muscle fibers are ripped and stretched, delaying the healing process.

It may take 4-6 weeks for an injury to heal. Sleeping is tough and many patients find that sleeping upright or in a recliner is easier, since the ribs don’t have to lift up against gravity like they do when lying flat. Still after a few hours of sleep, those muscles go into spasm and the first twist and move in the morning after they finally get comfortable can be excruciating and dreaded beginning on morning number 2. Fortunately, one morning, perhaps in a couple of weeks, that first move hurts a little less and there is a light at the end of the tunnel.

Ice is one of the basics of treatment, as is ibuprofen as anti-inflammatory, but wrapping ribs prevents deep breaths and is no longer recommended. Instead, many patients get sent home with an incentive spirometer, a plastic toy that gives a visual clue about how deep the needed breath has to be. All this suffering is inflicted to prevent pneumonia, the lung infection characterized by fever, cough and shortness of breath.

Intercostal muscle injuries are frustrating. While Mr. Wright and the Mets hope that he heals quickly and is ready for opening day, there is no quick fix to shorten the recovery time.  And just like barbeque, you know it’s ready, when it’s ready…a not a moment sooner.

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