Tony Romo - fractured rib AND pneumothorax

People may call Tony Romo a pretty-boy, but he sure takes the physical punishment. He recently fractured one rib AND was diagnosed with a pneumothorax in last week's game against the 49ers. Oh, and he came back to lead his team to victory before being diagnosed with these two conditions. No big deal. Also, this is the same guy who fractured his left clavicle last year.

I'll discuss both of these diagnoses below.

Fractured rib
You may want to scoff at the fact that I'm making a big deal of Romo coming back to play with a fractured rib, but hold your judgment. Sure, it's a small bone, and it's not involved in running or throwing, and you don't really cast it... but it #%$*ing hurts. Think about it: with a fracture of any of the long bones, you can rest, immobilize it, or plain just stop using it. Now guess what bones move every time you inhale or exhale. Yeah, those ribs... and you can't stop it.

Pain is such an issue with rib fractures that analgesia is the cornerstone of management of rib fractures on an inpatient basis. The reason for this is not only to make sure the patient isn't in excruciating pain every time they breathe, but if pain management isn't under control it can lead to irregular chest movements and breathing which can lead to a pneumonia (complication of 11-17% of patients under 65 with rib fractures). In fact, patients with 3 or more rib fractures are usually admitted to hospital for observation.

Fortunately for Romo, he only fractured one rib which can sometimes be controlled with just non-steroidal anti-inflammatories plus or minus opioids. With that said, most people with rib fractures aren't playing football right away. It's probably an interesting balancing act the training staff have to make with him. Not only is he going to be aggravating the injury (heavy breathing, fast twisting, moving arms/shoulders, more trauma from hits, ie. DeAngelo Hall) but they have to balance how they control his pain. Opioids usually work well for analgesia, but they will inevitably cause sedation, decreased reaction time, or drowsiness, which isn't usually the best side effect profile for a guy who has to make split-second decisions.

We'll see what happens tomorrow night...


Pneumothorax (aka "punctured lung")

Figure 1: NOT Tony Romo's CT scan,
but it does show a pneumothorax
(photo credit: Wikipedia)

Punctured lung is kind of a strange way of putting it (I guess unless his lung was actually physically damaged). Usually a pneumothorax refers to a "collapsed lung" which occurs when air gets in between the lung and the rest of the cavity, preventing the lung from inflating completely. Bigger ones can actually become medical emergencies, like what happened to Drew Bledsoe ten years ago.

To the right is a CT scan of a pneumothorax (i.e. NOT Tony Rom's CT). It's a pretty big one but it also makes it easy to see what happened. When reading CTs, the left lung is on the right and vice versa. You can see in this case the right lung (on the left) is a lot smaller and there's some black (air) surrounding it. That air in the pleural cavity is preventing the lung from inflating fully.

Fortunately for Romo (again), the pneumothorax was quoted as being "very small" (see ESPN article above). I assume that since no invasive treatment was mentioned, it was likely smaller than 3 cm and didn't require anything drastic to re-inflate the lung. A pneumothorax that is <3 cm can just be treated with supplemental oxygen and monitored. Supplemental oxygen can actually help the lung tissue resorb the free air in the cavity spontaneously. Usually if it's larger than that and/or it is causing the patient pain or to be short of breath  it may need to be drained via a needle or inserting a chest tube to relieve the pressurized air. Doesn't sound fun, does it?


In the end, the fractured rib to me is more of a fascinating storyline to follow tomorrow night than the pneumothorax given that after another CT scan Thursday it seems to have resolved. Once again, we don't know Romo's medical information and all of what I discussed above is speculation and a lot of what-ifs, but still interesting nonetheless.