novel treatments of rib fractures: hype or future?
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Novel Treatments of Rib Fractures: Hype or Future?. Phillip Chang, MD, FACS Trauma & Acute Care Surgery University of Kentucky. KY Trauma Symposium Nov 11, 2010. Objectives . Anatomy and Definition - PowerPoint PPT PresentationTRANSCRIPT
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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Become?
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