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%

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 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 fractures Pieracci et al Department of Surgery at Denver Health Medical Center Journal 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

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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