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Novel Treatments of Rib Fractures: Hype or Future?

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

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Novel Treatments of Rib Fractures: Hype or Future?

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  1. 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

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

  3. Anatomy – intercostal nerves

  4. Not all rib fractures are equally • 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

  5. Flail Chest • >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

  6. Flail chest & Pulmonary contusion • 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 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

  7. Pain control • 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.

  8. not quite the “good stuff” yet…. • 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

  9. Epidural Analgesia • 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

  10. Epidural Catheter • 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 Advantages Disadvantages

  11. Thoracic paravertebral block • 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 Advantages Disadvantages Continuous Thoracic Paravertebral Infusion of Bupivacaine for Pain Management in Patients With Multiple Fractured Ribs* Karmakar et al. Chest. 2003 Feb

  12. Pain control: thoracic paravertebral block

  13. On-Q pump

  14. Literature from thoracic surgeon • 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 intracostalcatheters for pain management after thoracotomy Allen el al. Annals of Thoracic Surgery, 2009.

  15. Epidural vs thoracic paravertebral infusion • 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

  16. Flail Chest: “internal pneumatic stabilization” • Complications of prolonged ventilation • Ventilator associated pneumonia • Tracheal stenosis • Ventilator associated lung injury • pneumothorax

  17. Judet’s struts 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

  18. Rib fixation Survey • 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

  19. Rib fracture fixation: old school External fixation with traction - early 20th century Trauma.org

  20. Want to Learn?

  21. Become?

  22. Various rib fixation options

  23. Rib fixation vs. Ventilator 64 patients with primarily flail chest and pulmonary contusion over 10 years in UAE Management of flail chest injury: Internal fixation versus endotracheal intubation and ventilation Ahmed et al. Journal of Thoracic and Cardiovascular Surgery, 1995

  24. Ventilator days • Medical College of Wisconsin • 1996-2000 • Matched, case-controlled study • 30 patients each • Struts used after thoracotomy Rib fracture stabilization in patients sustaining blunt chest trauma Nirula et al. American Surgeon, 2006

  25. Pulmonary Function after Fixation • 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

  26. Prospective Trial from Japan • 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

  27. Immediate Results

  28. Long-term Results Forced expiratory functional capacity, 0-12 months

  29. Paravertebral intercostal nerve block Rib fixation for pain Rib fixation for vent failure Ventilator Epidural P.O. Pain Rib fixation for flail

  30. an “Italian” Algorithm Surgical Stabilization of Severe Flail Chest Casali, et al. CTSnet, 2005

  31. Chest trauma with rib fx Single / few rib fx Unilateral rib series fx Bilateral rib series fx Not true flail chest Intubated & not True flail chest with or without sternum fx. Intubated & not Adequate pain med. PO vsi.v Resp. training VC ≥800 No flail chest not intubated Flail chest Intubated or not VC ≥800 & Adequate pain ORIF only (ant./lat.fx.) ORIF only ant./lat. for displaced fx Bilateral ORIF only ant./lat. + sternum ORIF if displaced OnQ Pump Consider OnQ Pump for 72 hrs post op VC< 800 Pain score >7 COPD Patient OnQ Pump for Contralateral Side VC= Vital Capacity tested on incentive spirometer ORIF only (ant./lat.fx) Hasenboehler Suggested SGB Trauma protocol 2010 Raminder et al World J Surg (2009) 33:14–22

  32. Step 1: positioning

  33. Pulmonary function testing after operative stabilisation of the chest wall for Flail chest Lardinois et al. European Journal of Cardio-thoracic Surgery 2001

  34. Precontoured Titanium Locking Plates • Precontoured plates • 4 plates each side • Right = Rose-red • Left = Light blue • Profile 1.5mm • 15, 16, 17 and 18 holes • Universal plate • 8 holes • Gold

  35. 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

  36. Step 4: customize plate

  37. Step 5: Just drill & screw ?

  38. A case at UK • 64 yo male, MVC • Injuries: • Rib fractures: left 4-10 with 4-7 flail right 2nd& 5th • Left hemothorax • Manubriumfx • Right acetabularfx • Left fibula fx • ICU not intubated • GCS = 15 / ISS 25 • COPD • TV Max 300ml preop.

  39. Pre-op images

  40. Pre-op planning

  41. Pre-operative

  42. Rib fixation

  43. Post-operative

  44. Post-op CXR

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

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