Novel Treatments of Rib Fractures * Hype or Future?

Report
Phillip Chang, MD, FACS
Trauma & Acute Care Surgery
University of Kentucky
KY Trauma Symposium
Nov 11, 2010
Anatomy and Definition
 Review traditional therapies
 Review of the literature
 Discuss novel therapies
 UK Case example
 Finish on-time
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10% of trauma patients have rib fractures
 under reported - up to 50% of fractures may be undetected
radiographically

Elderly (age ≥ 65)
20.1% mortality vs. 11.4%

Number of ribs matter
 1-4 rib fractures: 5.4% mortality
 ≥5 rib fractures: 8.9% mortality

Associated pulmonary contusion thought to be underlying
cause of long term dysfunction
Rib Fractures in the Elderly: a marker of injury severity.
Stawicki et al. Journal of American Geriatrics Society, 2004
TsO2 management of flail chest in trauma: Analysis of risk factors affecting outcome.
Ali et al. ANZ Journal of Surgery, 2007
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>3 adjacent ribs, fractured in at
least two places
Paradoxical respiration
75 per 50,000 patients per year
1-2 cases per month for each
trauma center
Pulmonary contusion is key
problem
Decreased compliance
Increased shunting
Decreased: HLO 33%
Morbidity 20%
Mortality: 0%
Management of flail chest without mechanical ventilation.
Trinkle JK et al. Annals Thoracic Surgery, 1975

Ventilation – perfusion mismatch
◦ APRV, CPAP (non intubated), prone

Maintaining pulmonary toilet
◦ Physiotherapy, NT suctioning
◦ Timely tracheostomy

Adequate fluid resuscitation
◦ Colloids?
◦ Hypertonic saline?

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Pain management
Possible surgical fixation
Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion.
Voggenreiter et al. J Am. Coll Surg. 1998
Management of Flail Chest Miller et al. Can. Med. Ass. J. 1983

NSAID
• Limited in renal dysfunction and/or history of peptic
ulcer disease

Oral Narcotics
• Ileus
• dependency

IV narcotics (including IVPCA)
• Sedation
• Cough suppression
• Respiratory depression/hypoxemia

Rib taping/rib belts
• Not shown to beneficial
A randomized clinical trial of rib belts for simple fractures. Quick G.
American journal of Emergency Medicine, 1990.

Local rib blocks
• Only lasts ~6 hours
• Repeated injections may lead to
toxicity
• Upper ribs difficult

Intrapleural infusion catheters
• like a chest tube
• Actual chest tube causes loss of
anesthetics
• Could clamp intermittently
• Semi-recumbent position leads to
dependent pooling of local
anesthetics

EAST practice guideline:
• Level 1 “clinical application
of pain management
modalities to treatment of
blunt thoracic trauma”
Epidural analgesia is the optimal
modality of pain relief for blunt
chest wall injury and is the
preferred technique after severe
blunt thoracic trauma.
• Level II “technical aspect”
Combination of narcotic
(fentanyl) & local (bupivicaine)
is preferred
Pain Management in Blunt Thoracic Trauma. EAST guideline. Journal of Trauma,
2005
Advantages


Increased functional
residual capacity (FRC),
lung compliance, vital
capacity
Remain awake –
pulmonary toilet
Disadvantages

relative contraindicated:
• Spine fracture
• High rib fractures
• Sedated/intubated patients
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Cause hypotension
Infection – rare
Hematoma
“high block” – respiratory
insufficiency
Narcotic component
• Nausea/vomiting
Advantages

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


Does not require
painful palpation of
ribs
Not limited by
scapula
No risk of spinal
cord injury
Can be used on
sedated patients
Hypotension rare
Disadvantages


Complications:
◦ Pneumothorax
◦ Vascular injury
Lack of literature
support
Continuous Thoracic Paravertebral Infusion of Bupivacaine for Pain
Management in Patients With Multiple Fractured Ribs*
Karmakar et al. Chest. 2003 Feb

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Mayo clinic
Randomized controlled
trial
124 patients had
catheters placed after
thoracotomy
◦ 60 received
bupivicaine
◦ 64 reveived placebo
◦ All had epidural
catheter until POD#3
A randomized controlled trial of bupivacaine through intracostal catheters for
pain management after thoracotomy
Allen el al. Annals of Thoracic Surgery, 2009.
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India
Prospective randomized
30 patients
Unilateral rib fracture
Epidural vs. TPVB
Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral
infusion in patients with unilateral multiple fractured ribs – a pilot study
Mohta et al. Journal of Trauma, 2009

Complications of
prolonged ventilation
◦ Ventilator associated
pneumonia
◦ Tracheal stenosis
◦ Ventilator associated lung
injury
◦ pneumothorax
Indicatons and Surgical Treatment of theTraumatic Flail Chest Syndrome: An original Technique.
Sanchez-Lloret J. et al: Thorac. Cardiovasc. Surgeon. 1982.
Treatment of flail chest with Judet’s struts.
Menard et al. J Thoracic Cardiovascular Surgery, 1983

Survey 405 US surgeons
(all from Level 1 and Teaching H.)
◦ 238 trauma surgeons
◦ 97 orthopedic surgeons
◦ 70 thoracic surgeons

>1 Surgical indication
◦ Trauma: 82%
◦ Ortho: 66%
◦ Thoracic: 71%
Knowledge on published randomized trials 16% TRS, 3%OS, and 8%THS
Surveyed opinion of American trauma, Orthopedic, and Thoracic surgeons on Rib and Sternal Fracture repair.
Mayberry et al. Journal of Trauma, 2009
External fixation with traction
- early 20th century
Trauma.org
64 patients with primarily flail
chest and pulmonary contusion
over 10 years in UAE
Fixation
(n=26)
Ventilator
(n=38)
Vent
(days)
1.3 (80%)
3.9 (total)
after fixation
15
Trach
11%
37%
VAP
15%
50%
Mortality
8%
29%
ICU LOS
9 days
21 days
Management of flail chest injury: Internal fixation versus endotracheal intubation and ventilation
Ahmed et al. Journal of Thoracic and Cardiovascular Surgery, 1995

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Medical College of
Wisconsin
1996-2000
Matched, casecontrolled study
30 patients each
Struts used after
thoracotomy
Rib fracture stabilization in patients sustaining blunt chest trauma
Nirula et al. American Surgeon, 2006
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Berne, Switzerland
Prospective evaluation
Surg. Stabilization of flail chest
1990-1999
66 patients
◦ Median time to fixation: 2.8
days
◦ Extubation 7d. post-op: 85%
◦ 30 day Mortality 11% (ARDS)
Significant difference at 6 months of predicted vs. recorded TLC
Line = 85% of value of the predicted TLC
Pulmonary function testing after operative stabilisation of the chest wall for Flail chest
Lardinois et al. European Journal of Cardio-thoracic Surgery 2001

37 consecutive flail
chest patients
◦ Randomization after 5
days on vent
◦ 18 rib fixation
◦ 19 internal pneumatic
Surgical Stabilization of Internal Pneumatic Stabilization? A Prospective Randomized Study of Management of
Severe Flail Chest Patients.
Tanakaet al. Journal of Trauma, 2002
Surgical (n=18)
“internal” (n=19)
Pneumonia, day 7
5%
16%
NS
Pneumonia, day 21
22%
90%
<.05
Ventilator days, total
(post-op)
10.8 (2.5)
18.3
<.05
Tracheostomy, day 7
0
5/19
NS
Tracheostomy, day
21
3/18
15/19
<.05
Total ICU stay (postop)
16.5 (9.2)
26.8
<.05
Medical expense
$13,455
$23,423
<0.5
Forced expiratory functional capacity,
0-12 months
Paravertebral intercostal nerve block
Rib fixation for pain
Rib fixation for vent failure
Ventilator
Epidural
P.O. Pain
Rib fixation for flail
Surgical Stabilization of Severe Flail Chest
Casali, et al. CTSnet, 2005
Chest trauma with rib fx
Single / few rib fx
Unilateral rib series fx
Adequate pain med.
PO vs i.v
Resp. training
VC ≥800
No flail chest
not intubated
VC ≥800 &
Adequate pain
OnQ Pump
VC< 800
Pain score >7
COPD Patient
ORIF only
(ant./lat.fx)
Bilateral rib series fx
Flail chest
Intubated or not
ORIF only
(ant./lat.fx.)
Not true flail
chest
Intubated & not
ORIF only
ant./lat. for
displaced fx
Consider
OnQ Pump
for 72 hrs
post op
True flail chest
with or without
sternum fx.
Intubated & not
Bilateral ORIF
only ant./lat.
+ sternum ORIF
if displaced
OnQ Pump for
Contralateral Side
VC= Vital Capacity tested on incentive spirometer
Hasenboehler Suggested SGB Trauma protocol 2010
Raminder et al World J Surg (2009) 33:14–22
Pulmonary function testing after operative stabilisation of the chest wall for Flail chest
Lardinois et al. European Journal of Cardio-thoracic Surgery 2001
Precontoured Titanium Locking Plates
Precontoured plates

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4 plates each side
Right = Rose-red
Left = Light blue
Profile 1.5mm
15, 16, 17 and 18
holes
Universal plate
8 holes
 Gold


3 Widths
◦
◦
◦
Small – 3 mm
Medium – 4 mm
Large – 5 mm
Length 92.5 mm (75
mm in IM canal)
 Ideal for Posterior
Fractures
 Minimally invasive
 One screw to secure
splint
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64 yo male, MVC
Injuries:
Rib fractures: left 4-10 with 4-7 flail
right 2nd& 5th
Left hemothorax
Manubrium fx
Right acetabular fx
Left fibula fx
ICU not intubated
GCS = 15 / ISS 25
COPD
TV Max 300ml preop.

OR on HD #3
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Extubation on HD #4 (1 days vent.)
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TV 900ml postop.
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Discharged 16 days later to rehab

Pulmonary toilet, pain control are key

Local paravertebral anesthesia can be an adjunct

Rib fixation
 Consider within 5 days of injury
 Liberal use of 3-D CT scan images
 Locking plates
 Elderly patients with brittle bones can be done
 Every fracture does not need to be fixed
 Thoracotomy and double-lumen intubation not necessary

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