Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been established and are considered controversial The outcome of a strictly nonoperative approach may not be optimal Potential indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication Rib fracture repair is technically challenging secondary to the human rib’s relatively thin cortex and its tendency to fracture obliquely Nonetheless, several effective repair systems have been developed Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials

Rib fracture repair: indications, technical issues, and future directions

BACKGROUND: Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC. METHODS: A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus. RESULTS: Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations. CONCLUSION: Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated. A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected. Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible. Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure. (J Trauma Acute Care Surg. 2012;73: S351YS361. Copyright * 2012 by Lippincott Williams & Wilkins)

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Management of pulmonary contusion and flail chest: An eastern association for the surgery of trauma practice management guideline

In the 2010 US Census, the number of persons age 65 years and older constituted 13% of the population and is projected to constitute 22% of the population by 2020.1 As the US population ages, there is an increasing volume of GTPs; injury is now the seventh leading cause of death for those age 65 years.2 Geriatric trauma is increasing both in absolute number and as a proportion of annual volume presenting to trauma centers. Based on the National Trauma Data Bank, the proportion of trauma patients aged 65 years or older in Level I and II trauma centers increased from 23% in 2003 to 30% in 2009. This is likely a significant underestimate because most GTPs are treated at lower-level or nontrauma centers.3,4 In Washington State, for example, the annual number of GTPs in the state registry has increased from 4,266 in 2000 to 11,226 in 2012, an increase from 30% to 42% of the total trauma population. Clearly, the management of injury in geriatric patients will continue to be a major challenge for trauma care providers.

In his presidential address to the AAST entitled “For the care of the undeserved,” Dr. Robert Mackersie identified the growing population of elderly injured patients as medically underserved in terms of limited trauma center access, age-related treatment biases, and as a result, deprived of many of the recent advances in modern trauma care.5 To specifically address these inequalities, he convened an Ad Hoc Geriatric Committee and charged it, “To advise the AAST regarding the problems, issues, and needs of the geriatric patient.” What follows is the work product of the Committee in responding to President Mackersie’s charge. The initial priority was to survey the membership of the AAST to better understand the current conditions under which hospitalized GTPs are receiving care. The second task of the Committee was to enumerate the major problems associated with the care of GTPs and to suggest potential solutions to the identified problems. While the Committee does not presume infallibility in its pronouncements, the material presented is intended to initiate discussion, stimulate research, and to ultimately result in evidence-based guidelines that will better serve this “underserved” segment of our population.

/pdf/injury-in-the-aged-geriatric-trauma-care-at-the-crossroads-zvnka1vlyp.pdf

Injury in the aged: Geriatric trauma care at the crossroads

Background The contribution of rib fractures to prolonged pain and disability may be underappreciated and undertreated. Clinicians are traditionally taught that the pain and disability of rib fractures resolves in 6 to 8 weeks. Methods This study was a prospective observation of 203 patients with rib fractures at a level 1 trauma center. Chest wall pain was evaluated by the McGill Pain Questionnaire (MPQ) pain rating index (PRI) and present pain intensity (PPI). Prolonged pain was defined as a PRI of 8 or more at 2 months after injury. Prolonged disability was defined as a decrease in 1 or more levels of work or functional status at 2 months after injury. Predictors of prolonged pain and disability were determined by multivariate analysis. Results One hundred forty-five male patients and 58 female patients with a mean injury severity score (ISS) of 20 (range, 1 to 59) had a mean of 5.4 rib fractures (range, 1 to 29). Forty-four (22%) patients had bilateral fractures, 15 (7%) had flail chest, and 92 (45%) had associated injury. One hundred eighty-seven patients were followed 2 months or more. One hundred ten (59%) patients had prolonged chest wall pain and 142 (76%) had prolonged disability. Among 111 patients with isolated rib fractures, 67 (64%) had prolonged chest wall pain and 69 (66%) had prolonged disability. MPQ PPI was predictive of prolonged pain (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.4 to 2.5), and prolonged disability (OR, 2.2; 95% CI, 1.5 to 3.4). The presence of significant associated injuries was predictive of prolonged disability (OR, 5.9; 95% CI, 1.4 to 29). Conclusions Prolonged chest wall pain is common, and the contribution of rib fractures to disability is greater than traditionally expected. Further investigation into more effective therapies that prevent prolonged pain and disability after rib fractures is needed.

http://lib.ajaums.ac.ir/booklist/1-s2.0-S0002961013001451-main.pdf

Prolonged pain and disability are common after rib fractures

BACKGROUNDThere is currently no scoring system for rib fractures that relates detailed anatomic variables to patient outcomes. Our objective was to develop and validate a radiographic rib fracture scoring system based on computed tomographic chest findings.METHODSWe reviewed our trauma registry from

RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy.

Background We initiated a multidisciplinary clinical pathway targeting patients greater than 45 years of age with more than 4 rib fractures. The purpose of the current study was to evaluate the effect of this pathway on infectious morbidity and mortality. Methods This was a prospective cohort study. Data evaluated included patient demographics, injury characteristics, pain management details, lengths of stay, morbidity, and mortality. Univariate and multivariate analyses were performed using a significance level of P Results When adjusting for age, injury severity score, and number of rib fractures, the clinical pathway was associated with decreased intensive care unit length of stay by 2.4 days (95% confidence interval [CI] −4.3, −0.52 days, P = .01) hospital length of stay by 3.7 days (95% CI −7.1, −0.42 days, P = .02), pneumonias (odds ratio [OR] 0.12, 95% CI 0.04 to 0.34, P P = .06). Conclusions Implementation of a rib fracture multidisciplinary clinical pathway decreased mechanical ventilator-dependent days, lengths of stay, infectious morbidity, and mortality.

A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients.

Background: We initiated a multidisciplinary clinical pathway targeting patients greater than 45 years of age with more than 4 rib fractures. The purpose of the current study was to evaluate the effect of this pathway on infectious morbidity and mortality. Methods: This was a prospective cohort study. Data evaluated included patient demographics, injury characteristics, pain management details, lengths of stay, morbidity, and mortality. Univariate and multivariate analyses were performed using a significance level of P .05. Results: When adjusting for age, injury severity score, and number of rib fractures, the clinical pathway was associated with decreased intensive care unit length of stay by 2.4 days (95% confidence interval [CI] 4.3, 0.52 days, P .01) hospital length of stay by 3.7 days (95% CI 7.1, 0.42 days, P .02), pneumonias (odds ratio [OR] 0.12, 95% CI 0.04 to 0.34, P .001), and mortality (OR 0.37, 95% CI 0.13 to 1.03, P .06). Conclusions: Implementation of a rib fracture multidisciplinary clinical pathway decreased mechanical ventilator-dependent days, lengths of stay, infectious morbidity, and mortality. © 2006 Excerpta Medica Inc. All rights reserved.

Papers presented A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients

Bobbie K. Brasseaux

Papers

A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients.

Papers presented A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients