Mark “Mo” Bandy: A 31-Year-Old Rodeo Rider With Broken Ribs After Being Thrown From a Bronco

Learning Objectives

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Learn the common causes of chest wall pain.
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Learn the common causes of fractured ribs.
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Develop an understanding of the anatomy of the ribs.
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Develop an understanding of the differential diagnosis of fractured ribs.
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Learn the clinical presentation of fractured ribs.
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Learn how to examine the lower extremity.
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Learn how to use physical examination to identify fractured ribs.
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Develop an understanding of the treatment options for fractured ribs.

Mo Bandy

Mark “Mo” Bandy is a 31-year-old rodeo rider with the chief complaint of, “I cracked some ribs.” I had been taking care of Mo for the last several years, and he was a real piece of work. Constantly nursing this injury or that, Mo was the walking textbook of musculoskeletal injuries. I had most recently treated him for a broken wrist after he was thrown from a horse. Mo had a degree in electrical engineering, but after working for a local engineering firm for less than 1 year, he just up and quit and starting riding broncos on the rodeo circuit. I had seen Mo ride, and I had to admit it was pretty impressive, but you couldn’t pay me a million bucks to get on one of those crazy horses.

This time it was Mo’s ribs. “Doc, you are looking a little tired. You need to get out and get some sun. Never too late to get a job as a rodeo clown.” With that he started to laugh, and immediately winced in pain. “Doc, I cracked me a couple of ribs and need you to wrap me up so I can ride this weekend.” I just shook my head and said, “Let me take a look.”

I asked Mo how his breathing was, and he said he felt a “little winded,” but it was the pain that was keeping him up at night. I asked Mo how he was sleeping, and he said, “Jack and I are sleeping just fine.” “Jack?” I asked. “Doc, you know Jack.” I shook my head, and said, “I don’t think I’ve had the pleasure.” Mo laughed, winced, and said, “Jack—Jack Daniels.” I laughed and said that perhaps he and “Jack” should spend some time apart. “Doc, Jack is the only thing letting me get any sleep, and that is in a chair. These damn ribs are a real nuisance when it comes to my sleep.” I asked Mo what he was doing for the pain, and he smiled and said, “Jack.” Mo laughed, winced, and said, “Damn it, Doc! Any time I move or cough, it makes me think about a career in electrical engineering.”

On physical examination, Mo was afebrile. His respirations were 18, his pulse was 78 and regular, and his blood pressure was 134/70. Mo’s head, eyes, ears, nose, throat (HEENT) exam was normal. He had a lot of upper airway secretions because it hurt too much to cough, and I thought his breath sounds were somewhat decreased on the right, but it was really hard to get Mo to take a big breath because of the pain. His cardiac examination was within normal limits, but I was a little worried about his lungs. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of Mo’s right chest wall revealed a large ecchymotic area that ran from his posterior axillary line to his umbilicus. It looked like his chest had been hit with a baseball bat. The right was a little warm, but there was no obvious infection. Gentle palpation caused Mo to wince in pain. I thought I could feel a couple of free-floating rib fragments. A careful neurologic examination of the upper extremities was completely normal. Deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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History of sudden onset of right chest wall pain after being thrown from a horse
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Significant bruising
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Patient notes feeling “a little winded”
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History of previous significant musculoskeletal injuries
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No fever or chills
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Significant sleep disturbance
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Pain with coughing or movement of the chest wall
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Using alcohol to treat the pain