General characteristics and contusions
By severity, injuries are divided into closed and open. The nature of closed injuries directly depends on the applied force: everyday incidents usually result in soft tissue contusions, whereas high-impact forces (car accidents, falls from height) lead to fractures.
Soft tissue contusions occur from a direct hit. The general condition of the child is usually not affected. Pain is constant and equally pronounced both at rest and during breathing. Both halves of the chest symmetrically participate in the breathing act. Locally, swelling, bruising, and tenderness are determined.
An important differential sign helps distinguish a bruise from a fracture: applying pressure to undamaged parts of the chest does not cause increased pain at the site of the bruise. Radiography is indicated only in doubtful cases to rule out occult fractures. Specific treatment is not required — physiotherapy and analgesics are sufficient.
Rib fractures
Can result from a direct blow or compression (an indirect mechanism yielding the most severe consequences).
Symptoms and diagnostics The main symptom is a clear relationship between the pain syndrome and movements: pain sharply increases on deep inhalation, coughing, or sneezing. The child accurately localizes the injury site. Breathing becomes shallow, shortness of breath appears, and the injured half of the chest lags behind during breathing.
Attention: when the clinical picture of a fracture is obvious, it is forbidden to palpate the broken rib or perform stress tests to clarify the localization.
If the fracture is complicated by lung parenchyma injury, hemoptysis and subcutaneous emphysema appear. In children, such combined injuries are significantly more severe than in adults, more often complicated by pleuropulmonary shock, and have a higher mortality rate. The extent of injuries is determined using targeted rib radiography and lung fluoroscopy.
Treatment approaches
- In uncomplicated fractures, the main goal is to relieve pain and ensure normal ventilation. Conduction intercostal novocaine blockade (5–10 ml of a 0.5% novocaine solution for each intercostal space at the injury level, as well as 1–2 ribs above and below) and general analgesics are used.
- Fixating bandages for isolated fractures are not used.
- To prevent pneumonia, UHF therapy and breathing exercises with expiratory resistance (blowing up rubber balloons, toys) are prescribed.
- Recovery takes 2–3 weeks.
Traumatic asphyxia (chest compression)
This is an extremely severe condition resulting from external chest compression (being trapped under debris, run over by a car).
Pathogenesis: sudden compression causes a sharp increase in intrathoracic pressure, leading to a reverse blood flow in the superior vena cava system. As a result, small veins of the head, neck, and upper body rupture.
Clinical picture:
- Gradually merging pinpoint hemorrhages appear on the skin of the upper body, neck, head, as well as on the conjunctiva and mucous membranes.
- Similar hemorrhages occur in the lung parenchyma, causing severe hypoxia.
- The condition occurs against the background of severe shock.
- Severe hemopneumothorax frequently develops due to injuries to the bronchi, lungs, and large vessels.
Treatment is based on powerful anti-shock measures. At the pre-hospital stage, cervical vagosympathetic blockade, oxygen therapy, and blood substitutes are administered. In the hospital, treatment is continued in the shock trauma bay (therapeutic anesthesia, infusion-transfusion therapy). Pleural cavity drainage is performed according to indications, and surgery is used if hemopneumothorax progresses.
Sternal fracture
A rare injury in children resulting from a direct impact. The typical localization is the area of junction between the manubrium and the body of the sternum.
- Without displacement: subcutaneous hematoma and sharp local pain, worsening with breathing and movements.
- With fragment displacement: the peripheral fragment usually displaces dorsally, resulting in a step-like deformity palpable upon examination.
The diagnosis is confirmed instrumentally (radiography). Treatment begins with anesthesia of the fracture site using a 0.5–1% novocaine solution.
Briefly: answers to topical questions
What complications can develop in closed rib fractures in children?
Closed rib fractures in children can lead to injuries of internal chest cavity organs and severe shock states. The main complications include:
- Lung parenchyma injury — accompanied by hemoptysis and subcutaneous emphysema in the injury area.
- Pneumothorax — accumulation of air in the pleural cavity.
- Mediastinal injuries — injuries to the anterior or posterior mediastinum.
- Pleuropulmonary shock — a severe complication that is more severe in children than in adults and has a higher mortality rate.
What is the technique for performing Vishnevsky cervical vagosympathetic blockade?
The technique for Vishnevsky cervical vagosympathetic blockade:
- Patient positioning — supine with a roll under the shoulder blades, head turned to the opposite side.
- Injection point — at the posterior edge of the sternocleidomastoid muscle, above its intersection with the external jugular vein.
- Manipulation — after skin anesthesia, the muscle with the vascular bundle is displaced medially with the left index finger.
- Needle insertion — a long needle is directed upward and medially toward the anterior surface of the spine, then withdrawn by 0.5 cm.
- Solution administration — 40–50 ml of a 0.25% novocaine solution is injected into the tissue behind the common fascial sheath using the "creeping infiltrate" principle.
For the differential diagnosis of a contusion and a rib fracture, remember the load rule: when compressing the chest far from the injury site, pain in the focus intensifies only in case of a fracture.
Class and exam questions
Should a tight bandage be applied for a rib fracture in a child?
Categorically no. Fixation bandages restrict chest excursion, impair pulmonary ventilation, and contribute to the development of hypostatic pneumonia.
How does traumatic asphyxia manifest externally?
The appearance of pinpoint hemorrhages (petechiae) on the face, neck, upper body, as well as on the conjunctiva and mucous membranes of the nose and mouth is characteristic.
What to do if a rib fracture is clinically obvious?
One should not purposely palpate the broken rib or perform stress tests to avoid causing unnecessary pain and provoking pleural damage from bone fragments. Radiography is sufficient.
What else to study on this topic
- Mechanism of development of pleuropulmonary shock in combined injuries in children
- Radiological picture of pneumothorax and mediastinal injuries
- Technique of conduction intercostal and cervical vagosympathetic blockades
- Infusion-transfusion therapy protocol in traumatic asphyxia
- Surgical tactics and indications for thoracotomy in hemopneumothorax
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Other topics in the section "Specifics of bone and joint injuries in children"
Entire section "Specifics of bone and joint injuries in children"Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.