Novel Treatments of Rib Fractures:

Hype or Future?Phillip Chang, MD, FACS

Trauma & Acute Care SurgeryUniversity of Kentucky

KY Trauma SymposiumNov 11, 2010

Anatomy and Definition Review traditional therapies Review of the literature Discuss novel therapies UK Case example Finish on-time

Objectives

Anatomy – intercostal nerves

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

Not all rib fractures are equally

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

>3 adjacent ribs, fractured in at least two places

Paradoxical respiration 75 per 50,000 patients per

year1-2 cases per month for each

trauma center Pulmonary contusion is key

problemDecreased complianceIncreased shunting

Decreased: HLO 33%Morbidity 20%Mortality: 0%

Flail Chest

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?

Pain management Possible surgical fixation

Flail chest & Pulmonary contusion

Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion.

Voggenreiter et al. J Am. Coll Surg. 1998Management of Flail Chest Miller et al. Can. Med. Ass. J. 1983

NSAID• Limited in renal dysfunction and/or history of peptic

ulcer diseaseOral Narcotics

• Ileus• dependency

IV narcotics (including IVPCA)• Sedation• Cough suppression• Respiratory depression/hypoxemia

Rib taping/rib belts• Not shown to beneficial

Pain control

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

not quite the “good stuff” yet….

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

Epidural Analgesia

Pain Management in Blunt Thoracic Trauma. EAST guideline. Journal of Trauma, 2005

Epidural Catheter

Advantages Disadvantages Increased functional

residual capacity (FRC), lung compliance, vital capacity

Remain awake – pulmonary toilet

relative contraindicated:• Spine fracture• High rib fractures• Sedated/intubated patients

Cause hypotension Infection – rare Hematoma “high block” –

respiratory insufficiency Narcotic component

• Nausea/vomiting

Thoracic paravertebral block

Advantages Disadvantages 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

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

Pain control: thoracic paravertebral block

On-Q pump

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

Literature from thoracic surgeon

A randomized controlled trial of bupivacaine through intracostal catheters for pain management after thoracotomy

Allen el al. Annals of Thoracic Surgery, 2009.

India Prospective randomized 30 patients Unilateral rib fracture Epidural vs. TPVB

Epidural vs thoracic paravertebral infusion

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

Flail Chest: “internal pneumatic stabilization”

Judet’s struts

Treatment of flail chest with Judet’s struts. Menard et al. J Thoracic Cardiovascular Surgery, 1983

Indicatons and Surgical Treatment of theTraumatic Flail Chest Syndrome: An original Technique.

Sanchez-Lloret J. et al: Thorac. Cardiovasc. Surgeon. 1982.

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%

Rib fixation Survey

Surveyed opinion of American trauma, Orthopedic, and Thoracic surgeons on Rib and Sternal Fracture repair.Mayberry et al. Journal of Trauma, 2009

Knowledge on published randomized trials 16% TRS, 3%OS, and 8%THS

Rib fracture fixation: old school

Trauma.org

External fixation with traction- early 20th century

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Various rib fixation options

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

Rib fixation vs. Ventilator

Management of flail chest injury: Internal fixation versus endotracheal intubation and ventilationAhmed et al. Journal of Thoracic and Cardiovascular Surgery, 1995

64 patients with primarily flail chest and pulmonary contusion over 10 years in UAE

Medical College of Wisconsin

1996-2000 Matched, case-

controlled study 30 patients each Struts used after

thoracotomy

Ventilator days

Rib fracture stabilization in patients sustaining blunt chest traumaNirula et al. American Surgeon, 2006

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)

Pulmonary Function after Fixation

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

Prospective Trial from Japan

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 (post-op)

16.5 (9.2) 26.8 <.05

Medical expense $13,455 $23,423 <0.5

Immediate Results

Long-term Results

Forced expiratory functional capacity, 0-12 months

Paravertebral intercostal nerve block

Rib fixation for pain

Epidural

P.O. Pain

Rib fixation for vent failure

Rib fixation for flail

Ventilator

an “Italian” Algorithm

Surgical Stabilization of Severe Flail ChestCasali, et al. CTSnet, 2005

Chest trauma with rib fx

Single / few rib fx Unilateral rib series fx Bilateral rib series fx

Adequate pain med. PO vs i.v

Resp. trainingVC ≥800

No flail chestnot intubated

Flail chest Intubated or not

True flail chest with or without

sternum fx.Intubated & not

Not true flail chest

Intubated & not

VC ≥800 &Adequate pain

VC< 800 Pain score >7 COPD Patient

ORIF only (ant./lat.fx.) ORIF only

ant./lat. fordisplaced fx

Bilateral ORIF only ant./lat.

+ sternum ORIFif displaced

OnQ Pump for Contralateral Side

OnQ Pump

ORIF only (ant./lat.fx)

Consider OnQ Pump for 72 hrs post op

Raminder et al World J Surg (2009) 33:14–22Hasenboehler Suggested SGB Trauma protocol 2010

VC= Vital Capacity tested on incentive spirometer

Step 1: positioning

Pulmonary function testing after operative stabilisation of the chest wall for Flail chest

Lardinois et al. European Journal of Cardio-thoracic Surgery 2001

Precontoured plates 4 plates each side Right = Rose-red Left = Light blue Profile 1.5mm 15, 16, 17 and 18

holesUniversal plate 8 holes Gold

Precontoured Titanium Locking Plates

Intramedullary Splints 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

Step 4: customize plate

Step 5: Just drill & screw ?

64 yo male, MVC Injuries:

Rib fractures: left 4-10 with 4-7 flail right 2nd& 5th

Left hemothoraxManubrium fxRight acetabular fxLeft fibula fx

ICU not intubated GCS = 15 / ISS 25 COPD TV Max 300ml preop.

A case at UK

Pre-op images

Pre-op planning

Pre-operative

Rib fixation

Post-operative

Post-op CXR

OR on HD #3 Extubation on HD #4 (1 days vent.) TV 900ml postop. Discharged 16 days later to rehab

Hospital course

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

What we DO know

Thank you