Generality
Costal volet is a potentially lethal medical condition, characterized by the paradoxical movement of a group of at least three ribs that have suffered a fracture in at least two distinct points.
The typical symptoms of costal volatility are chest pain and dyspnea.
Being a dangerous condition, costal care requires proper and timely medical treatment.
Anatomical recall on rib cage and ribs
The thoracic cage is the skeletal structure placed in the upper part of the human body, exactly between the neck and the diaphragm, which serves to protect vital organs (such as the heart and lungs) and important blood vessels (aorta, veins, cavities, etc.).
According to the anatomy manuals, it includes:
- Later, the 12 thoracic vertebrae ;
- Latero-anteriorly, 12 pairs of ribs (or ribs );
- Anteriorly, the costal cartilages and a bone called the sternum .
Each pair of ribs is connected to one of the 12 thoracic vertebrae; obviously, the left ribs emerge from the left side of the aforementioned vertebrae, while those on the right from the corresponding right side.
At their front end, the ribs articulate with the costal cartilages.
The space between the overlapping ribs is called the intercostal space .
In the intercostal space reside the so-called intercostal muscles - which play a fundamental role in expanding the thoracic cage, during the respiratory acts - numerous nerve endings (intercostal nerves), arterial blood vessels and venous blood vessels.
What is costal volet?
Costal volet is a potentially fatal medical condition, which consists of a partial or complete detachment of a group of ribs (minimum three, fractured at least two points) from the remaining rib cage.
This circumstance is extremely dangerous, because it can lead to respiratory failure . In fact, the group of low-cut ribs - which doctors call "segment" - can perform opposite movements to the physiological ones of the rest of the thoracic cage, compressing the lungs during the respiratory act.
In technical jargon, a movement with the aforementioned characteristics is called paradoxical movement .
OTHER DEFINITION OF COSTAL VOLET
According to another definition, the costal volet is the paradoxical movement of a rib cage segment, caused by the fracture of 3 or more ribs in at least two points.
SYNONYMS OF COSTAL VOLETS
The terms: mobile costal flap, mobile thoracic flap and flail chest are synonyms of costal volet.
Causes
At the origin of a costal volet there is generally a multiple fracture to the ribs . Multiple fractures to the ribs are fairly common injuries, due, in most cases, to chest trauma . Thus, traumatic events are the main causes of cost benefits.
Note: the doctors talk about multiple fractures in the ribs, when the fractured ribs are more than one and / or when the same rib breaks in at least two points.
POSSIBLE CAUSES OF A RABBIT FRACTURE
The traumatic events that most commonly cause the rupture of one or more ribs are: road accidents, falls on slippery ground or from stairs and game clashes during the practice of a sporting activity.
Figure: Contact sports like rugby are at high risk of rib fractures, so they also represent a possible cause of cost benefits.
RISK FACTORS
Given the cause-effect relationship between them, costal volleys and multiple rib fractures share the same risk factors. Among the latter, the two most important are:
- Osteoporosis . It is a systemic disease of the skeleton, which causes a strong weakening of the bones. The weakening results from the reduction of bone mass, a reduction which, in turn, is a consequence of the deterioration of the microarchitecture of the bone tissue.
Therefore, people with osteoporosis are more prone to fractures because they have more fragile bones than normal.
Osteoporosis affects the older age population more.
- The neoplastic lesions of the ribs . A malignant tumor, originating in a rib, weakens the latter, making it more fragile and particularly susceptible to multiple fractures.
In the very young population, costal vole is frequently associated with a congenital bone disease known as imperfect osteogenesis .
Imperfect osteogenesis is a rare pathological condition, supported by specific genetic mutations, which leads to an increase in skeletal fragility, a reduction in bone mass and a marked susceptibility to bone fractures.
WHAT CAUSES THE PARADOUS MOVEMENT?
To induce the paradoxical movement of the portion of the low-thoracic rib cage (ie the so-called costal segment), are the variations of the thoracic pressure with respect to the atmospheric one, taking place during normal breathing.
Indeed:
- During inspiration, the rib cage widens, thanks to the contribution of the diaphragm (which contracts and pushes the abdominal organs downwards) and the intercostal muscles. With the enlargement of the thoracic cage, the pressure inside the thoracic cavity becomes lower than the atmospheric one and the air enters the trachea more easily.
In the presence of costal volleys, the reduction of internal pressure in the chest causes an attraction towards the lungs of the low-cut segment of ribs.
- During expiration, the rib cage reduces its size (contracts), as the diaphragm and intercostal muscles release. With the reduction in the size of the rib cage, the pressure inside the chest rises and this involves the expulsion of the air introduced previously.
In the presence of costal conditions, the increase in internal thoracic pressure pushes the low-cut segment of ribs outwards.
As the reader can see, the movements of the costal segment, in situations of inspiration and expiration, are always opposite to those of the rest of the rib cage.
Epidemiology
The exact incidence of costal volet is not known.
However, according to reports from the Anglo-Saxon hospital centers, for every 13 patients who come to the hospital with a rib fracture, there is one affected by costal volet.
Symptoms and Complications
The symptoms that a patient with costal symptoms usually feels are: severe chest pain and dyspnea (or shortness of breath).
Chest pain has very specific features:
- Worsens during deep breathing;
- Worsens with the compression of the chest area, which has suffered the trauma;
- Worsens after certain twisting or bending movements of the body.
Dyspnea is explained by the paradoxical movement of the low-cut segment of ribs: this represents an obstacle to normal breathing.
Note: it is important to point out that chest pain is the typical symptom of rib fracture, so it is natural that it is also present at the costal time.
TYPICAL SIGNS
On the thoracic area affected by the trauma, people with costal volvidity often have swelling and hematoma .
Like chest pain, these two clinical signs are also typical of all rib fractures.
COMPLICATIONS
The mobile rib flap can be lethal when it causes a pneumothorax associated with severe respiratory failure . In fact, in such conditions, the lungs become stiff and the breaths gradually become more and more difficult.
The likelihood of complications is much higher the more severe the chest trauma and the involvement of the ribs are.
Complication common to all rib fractures
A complication common to all rib fractures, therefore also to those that do not cause costal volleys, is the onset of pneumonia or pulmonary infections of various kinds.
To induce the appearance of such conditions, sometimes even very dangerous, is the inability to perform deep breaths, due to severe pain. It is for this last reason that a crucial point in the modern therapy of rib fractures is the accurate treatment of painful symptoms.
Diagnosis
Doctors can suspect the presence of a costal factor starting from the physical examination, which consists mainly in the evaluation of symptoms.
However, to get more details, they have to resort to some radiological instrumental tests, such as chest X-ray (chest X-ray) and CT (Computerized Axial Tomography).
EXAMINATION OBJECTIVE
The objective examination is a necessary step in the diagnostic procedure, as the information it provides outlines the basic problem and what caused it.
During his execution, the doctor visits the patient, looking for any external clinical signs (hematomas, swelling, etc.); furthermore, he questions the patient about the symptoms:
- What are they?
- When did they appear? Did it trigger any particular event?
- What movements or gestures enhance the symptoms?
After the questionnaire, the physical examination ends with the palpation of the painful area (it is very important to understand if there is a paradoxical movement of a segment of ribs), the auscultation of the lungs and the heart (in search of any abnormal sounds ) and the analysis of the head, neck, spinal cord and belly.
INSTRUMENTAL EXAMINATIONS
Chest radiograph ( RX-thorax ) and CT scan allow the physician to identify the exact location of the fractured ribs that cause the costal volet.
However, it is necessary to specify two aspects:
- Some rib fractures, especially those that are not clear or positioned on the sides of the thoracic cage, are scarcely visible at the chest X-ray.
- Doctors use the TAC only if the physical examination and chest X-ray have not provided the information necessary for a definitive diagnosis; which is very rare.
Treatment
Patients with costal volition require immediate treatment.
The latter generally includes:
- The administration of analgesics, ie pain medications . Doctors generally prescribe a combination of opiates and NSAIDs (non-steroidal anti-inflammatory drugs). As far as opiates are concerned, the most used are some codeine derivatives, known as hydrocodone and oxycodone; as regards NSAIDs, however, the most prescribed are aspirin and ibuprofen.
The administration of analgesics, especially opiates, occurs by continuous epidural infusion, as it is the one that provides the best results. The infusion site is at the thoracic level, or at the supra-lumbar level.
- Positive pressure intubation and mechanical ventilation . These two treatments serve to replenish the patient's oxygen and support him in breathing. They are indispensable whenever a broken rib determines costal volet.
In general, doctors stop these treatments as soon as their lung function shows clear signs of recovery.
- The realization of a thoracic drainage (or chest tube) . It consists of the insertion, at the level of the pleural cavity, of a tube, which serves to remove air, blood and other possible fluids from the intrathoracic space. Doctors practice it to reduce the risk of pneumothorax, a condition that is one of the possible complications of positive pressure mechanical ventilation.
- The positioning of the patient in such a way that he is able to breathe deeply and without pain . Together with analgesic treatments, it helps prevent the onset of pneumonia and lung infections.
SURGICAL FIXATION OF THE FRACTURE
More than 50 years ago, doctors often resorted to surgical fixation of the fracture, a surgical procedure aimed at speeding up bone welding.
Then, for a variety of reasons, they felt it was appropriate not to use them anymore, because the risk of complications was higher than the benefits.
Recently, however, some studies have denied the above, showing that, if practiced in the very early stages, surgical fixation of the fracture can really have positive effects on the patient and reduce the duration of positive pressure mechanical ventilation.
Prognosis
The prognosis depends on the timeliness of the diagnosis and the application of the right treatments. A costal target identified in time is treatable with a good chance of success.
