I broke some ribs

It was a beautiful early spring day. I was working in a little patch of native plants, clearing away some pine needles and pulling dandelions. It was pretty much perfect weed picking soil, moist with spring rains but not muddy. In order to avoid stepping on the plants, I grabbed a vertical handrail support and swung myself up to the sidewalk and directly into the end of the rail. I felt and heard my rib cage crunch. Ow.

When I could breathe I found that, although it was painful, I could still do some things around the yard. I was pretty sure that it would get worse, so I worked a bit and then rested inside. It did get worse. Daily it became more painful so that on day 3 almost anything I did was excruciating. Twisting, leaning over, taking a deep breath, yawning, sneezing, coughing and taking a shower. Lying down in bed was a trick. As the song goes, the rib bone's connected to the everything else bone. There was no really pain free way to lie down, though there were positions that were more horrible than others. Lying motionless on my back was tolerable, but side sleeping was out (and will be for awhile.) Repositioning uses both arms and was mostly impossible.

Anti-inflammatory drugs were a little bit helpful. I'm shy of using opiates, but a low dose of hydrocodone made it possible to fall asleep lying on my back and not be bothered by the fact that I couldn't move. Even small doses of hydrocodone instantly stop my bowels, which was actually not such a problem since all of the activities of using the toilet were agonizing. The pain relief effect of hydrocodone wears off in 6 hours or less, unlike the constipating effects, which means that trying to get out of bed was even more of a problem than getting in it. None of that rolling on your side and pushing yourself up to a sitting position since rolling was horrible and pushing with the arm on that side recruited the muscles holding the ribs in position. It's not like I couldn't do it, it's just that it hurt like stink.

I have learned later in my injury that there is some controversy about splinting rib fractures. Soon after my injury, in about 2 days I think, muscle spasms in my chest wall began to be a problem. These happen with any fracture, when muscles that are protecting the injury pull taut, jamming the broken ends of the bone together and causing more muscle spasms. Splinting (which provides traction) is the answer. I found that I was able to tie a piece of cloth around my chest, just above the injured ribs and that allowed me to breathe and move with almost no spasms. After awhile the tightly tied cloth began to hurt but that could be managed by taking it off and icing the injury and then replacing it. The controversy arises because there is concern that a splint could reduce the depth of breathing and cause pneumonia. For me, at least, it was just the opposite. Splinting allowed me to take deeper breaths. The feedback of sharp pain with each breath gave me that "can't yawn" reflex which was relieved with the cloth binding. 

Breaking ribs is shockingly painful. Nothing to see from the outside, really, but wow. And it takes awhile for them to heal.

So now I have much more sympathy for people with broken ribs. But I really have no lived experience of how bad it can be.

In older people (probably older than I am, but I can't tell from the article abstract) rib fracture mortality can be around 10%. Quite a few of those are people with other injuries or who get pneumonia. Imagine. Pneumonia--your ribs hurt but then you have a fever and god forbid, a cough. Or if there is no cough you have nagging doctors and nurses insisting that you do cough and breathe deeply. And what if you have also broken an arm or a hand or a foot? My imagination goes wild. The spectrum of discomfort possible has all the colors of a bruise--the purple of agony, the green of nausea, the yellow of despair and the brown of helplessness.

How, you may ask, did I know that I had broken my ribs rather than just, say, bruised my chest wall? Did I get an x-ray? I could have gotten a chest x-ray which misses around 68% of rib fractures, or rib films specifically which supposedly miss none, but that would be painful and inconvenient, not to mention expensive (have I ever mentioned that American healthcare is too expensive?). Ultrasound, it turns out, is very sensitive for detection of rib fractures, especially if you know exactly where it hurts. I have been doing bedside ultrasound for years to evaluate rib fractures and there are drawbacks. Sometimes just touching the chest wall is nearly intolerable, so it takes practice to get it right. The sensitivity of ultrasound to detect a rib fracture is said to be around 91% compared to CT scans (which are assumed to be completely accurate but probably are not.) So I pointed my bedside ultrasound where it hurts and I found 3 rib fractures. The key findings, at least a few days after the injury, are a discontinuity in the cortex of the bone and often some edema around the injury. They are most obvious when imaged longitudinally, but a transverse view can show the cortex changing level as the transducer slides over the injury. 

What can be done for a rib fracture? I mentioned splinting, pain medication and anti-inflammatories, but there are also elastic chest binders with velcro closures which sound great except for the tiny problem that I can't imagine, at my worst, being able to pull open the velcro either to get it on or off. But that aside, they might be useful. Topical anti-inflammatories such as diclofenac gel sound like a great idea, but I did not notice any help at all. A lidocaine patch was initially a bit cooling but the benefit wore off really quickly after which time it just gave me a rash. K-T tape, a high tech medical tape for supporting injuries and tendinitis, is sometimes recommended but it just didn't provide enough traction. Patients in the hospital can get anesthetic agents through an epidural catheter or a nerve block, which are very effective and probably reduce the risk of death by allowing the patient to breathe and be up and around sooner. There is a condition known as flail chest, in which 3 or more ribs are broken in two or more places, resulting in an area of the chest wall that doesn't expand with breathing, rather it gets sucked in, making it harder to fill the lungs. For this kind of injury as well as very displaced fractures, orthopedic surgeons can actually place stabilizing hardware in the ribs, screwing plates over the fractures. Sounds painful. 

For me, the most useful procedure, outside of my tightly tied sarong, my anti-inflammatories and ice packs, was acupuncture. I had two acupuncture treatments in the acute period, in the week after my injury, and they seemed to really relieve pain and speed my healing. 

How long, then, is the healing phase? I expect to be mostly healed within a month of my injury, because this is getting really old. I read that it can take 3 months, but that's ridiculous and if it takes that long I will start writing letters to whoever's in charge.