management of rib fractures. clinical anatomy 12 pairs of ribs attach posteriorly to vertebrae rib...

Management of Rib Fractures

Clinical Anatomy • 12 pairs of ribs• Attach posteriorly to

vertebrae• Rib 8-12 are “false ribs”• Ribs 1-3 are relatively well

protected from injury by scapula, clavicle and soft tissue

• Ribs 9-12 are associated with intra-abdominal injuries

• Weakest at postero-lateral bend

Diagnosis

• Clinical suspicion– Blunt or penetrating

trauma• PE: localized

tenderness, crepitus, paradoxical movement

• CXR• CT • Bone scan

Flail chest • 3 or more adjacent ribs are each fractured in 2 places• Chest wall exhibits paradoxical movement • Often associated with significant pulmonary contusion • High risk for serious respiratory compromise• Mortality 33% • https://www.youtube.com/watch?v=mJ_FYwUqzsM

Management

• Always ABCs• Are the rib fractures associated with other injury? • Disposition

– Admit most patients with 3 or more rib fractures– ICU for elderly patient with 6 or more rib fractures

• Analgesia – NSAIDs, tylenol – Narcotics – Regional anesthesia– ePCA

• Pulmonary toilet

Complications

• Respiratory compromise• Pneumonia• Disability • Retained hemothorax • Death

Operative Management in the Old Days

Surgical management• Traditionally all rib fractures were managed non-operatively• New advancements in fixation systems, development of muscle

sparing techniques and favorable outcomes research have lead to renewed interest in surgical fixation

• Lack of consensus regarding indication and role• 3 small RCTs that have studied operative management of rib fractures

– Tanaka et al, J of Trauma, 2002– Granetsky et al, CT Surgery, 2005

• EAST Trauma practice guidelines recognize surgical fixation as level III recommendation for flail chest

• Surgical management of cases with non-flail chest remains very controversial

Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail ChestSilvana F Marasco, MSurg, FRACS, Andrew R Davies, FRACP, FCICM, Jamie Cooper,FRACP, FCICM, MD, Dinesh Varma, FRANZCR, Victoria Bennett, BNSc, CCRN , Rachael Nevill, Bnurs, Mark Fitzgerald, FACEMJournal of American College of Surgeons, 2013

- Prospective RCT, single institution study- Primary aim: to investigate the effect of

operative rib fixation of flail chest on mechanical ventilation time and ICU stay

- Secondary endpoints: PNA, PTX, failed extubation, tracheostomy rate, hospital stay, re-admission, cost

Methods

• 46 patients with traumatic flail chest requiring mechanical ventilation were enrolled between 2007 and 2011

• Patients randomized to operative or non-operative management

• IS and CT at 3 months• QOL survey at 6 months

Results • Duration of ICU stay: 285 vs 359 hours, p.03• Duration of mechanical ventilation was not significantly different,

151 vs 181 hrs, p 0.37• Required NIV post-extubation: 13 vs 19, p .05• Failed extubation: 3 vs 1 (0.61)• Tracheostomy: 9 vs 16, p 0.04• PNA: 11 vs 17, p0.07• Cost saving of $14K for patients who underwent rib fixation• Spirometry at 3 months: no significant difference in any parameter • CT at 3 months showed no difference healing• At 6 months, no difference in quality of life

Surgical stabilization of severe rib fracturesPieracci et al Department of Surgery at Denver Health Medical CenterJournal of Trauma and Acute Care Surgery April, 2015

• Single institution experience with SSRF

• Performed 50 SSRF in 2014

• Median number of fractures was 15

• 60% pts had flail chest

Indications

Technique

• Pre-operative planning • Timing: strive to perform as soon after injury as possible• Patient positioning • Bronchoscopy • Vary approach based on fracture position• Muscle sparing exposure when possible• Expose 3-5 cm on each side of fracture • Attempt to fix all fractures in surgical field • Double right angle technique used to obtain reduction of

fractures • Fixation with screwdriver system

Kit.

• https://www.youtube.com/watch?v=BW0IijZEaKw

Conclusions

• Limited evidence to support use of rib fixation for traumatic rib fractures

• Small RCTs support limited use of rib fixation to those patients who are mechanically ventilated with flail chest

• In select patient population in specialty center, it may be a beneficial treatment