Rib fractures

Seen in 10% of patients with multisystem trauma and 39% of patients of patients with blunt chest trauma.

Diagnosis

• CT - use NEXUS to determine need for CT

Injury patterns

• Ribs 4-9 are most common (these are almost the ribs most important for respiration)
• Injury to ribs 9-12 may be associated with injury to upper abdominal viscera
• Ribs 1-2 can be associated with blunt cerebrovascular injury, however this has been called into question recently with Mayo clinic data suggesting the risk of major vascular injury is very low
• Extremely posterior ribs fractures (within 3cm of transverse process) are usually well-tolerated, because they will be stabilised by the erector spinae musculature
• Very anterior fractures are cartilaginous - do not carry significant pulmonary morbidity
• Rib fractures in infants are very often non-accidental

Flail chest

• Need to differentiate between clinical and anatomical flail segments
  • Clinical: paradoxical chest wall movement (inwards during inspiration)
  • Anatomic - single rib that is fractured in two places (flail segment), thus floating free.
  • Flail CHEST = four or more consecutive ribs with flail segments.
• The negative pressure generated by inspiration within the thorax is dissipated by movement of the flail segment inward, thus reducing vital capacity and causing ineffective ventilation
• Clinical flail can be caused by a flail segment, but can also be seen with severely displaced contiguous rib fractures, or with bilateral rib fractures near the sternum
• Management
  • Adequate analgaesia
  • Early mechanical ventilation providing positive pressure if required
  • Humidified air
  • Aggressive chest physio with incentive spirometry
  • Deep suctioning including bronchoscopy
  • Indications for fixation:
    • Persistent pain
    • Severe chest wall instability
    • Progressive decline in pulmonary function
    • Inability to wean from ventilator despite optimal mechanical and pharmacological management
• Prognosis
  • Up to 75% of patients with either type of flail will have significant pulmonary morbidity, primarily pulmonary contusion
  • Mortality 16% in modern era

Assessment

• Look for risk factors FLOATS - if two or more, should be surg admit
  • Flail/PTX/HTX
  • Lung disease/left ventricular dysfunction
  • Old age >65
  • Assistance/aids for mobility
  • Three or more rib fractures
  • Sats <90 on RA

Management:

• Analgaesia
• Physiotherapy
• Respiratory supports
  • PPV is helpful if deterioration - NIV, CPAP, even intubation
• Consider ICU
• Fixation in certain cases

Analgaesia

• Standard regime from RMH: paracetamol, regular NSAID/COX2 inhibitor, PRN oxycodone (+/- gabapentin and tramadol)
• Step up to PCA +/- nerve block +/- ketamine (low-dose 1-3mcg/kg/min)
• Epidural anaesthesia was standard of care in bilateral rib fractures for a long time, but does cause hypotension, tethers the patient, >10% failure rate, epidural haematoma or infection, and spinal cord injury. Large matched analysis suggested no mortality benefit and increased respiratory complications. Should not be used with suspected abdominal injuries. Other relative contraindications: spinal fractures, history of spinal surgery, valvular heart disease, coagulopathy
• Serratus anterior block best for anterior fractures
• Erector spinae block - easy to place, good for posterior, lateral and anterior fractures, variable sensory block

Fixation

• Gaining popularity in 21st century. Small plates for extra-thoracic fixation. In select groups, decreases length of mechanical ventilation, need for tracheostomy, pneumonia, ICU LOS, hospital LOS, and overall cost.
• Usually intervene 24-72 hours post-injury
• Anatomy
  • Usually unnecessary for posterior ribs fractures - stabilised by scapula. Need to do it in prone if proceeding.
  • 1st, 2nd, 11th, 12th rib fractures usually don't need to be fixed
  • Anterior fractures
    • Easiest to access but hardest to fix
    • Costal cartilage doesn't hold screws
    • Fix to sternum or bridge to other side
  • Lateral
    • Posterolateral thoracotomy (muscle-sparing)
• RMH indications for thoracics referral: (get 3D recon on the CT prior)
  • Flail chest (across two ribs)
  • Severe chest wall deformity (including fractures to scapula and clavicle)
  • Loss of lung volume
  • Those at high risk, esp >65yo and pre-existing lung disease
  • Also, apparently, will only do it at RMH if 3 or more fractures require fixation
• Indications (all relative and cumulative chance of benefit):
  • Flail chest (anatomic or clinical)
  • 3 or more displaced rib fractures
  • Failure of medical management (pain >6 despite maximal therapy, respiratory insufficiency requiring ICU transfer or intubation) - this is the most important indication
  • During thoracotomy performed for another indication
  • Chronic non-union or mal-union
• Contraindications
  • Severe TBI - relative
  • Unstable spine - fairly absolute, until it is sorted
  • Pneumonia/early empyema
• Biggest RCT was from Alfred, where it was found to shorten ICU length of stay and requirement for NIV post-extubation, but did not change QoL at 3 or 6 months
• Options
  • Wires
  • Recon plates
  • Contoured plates
  • Absorbable plates
  • Rib-loc system
• Always do a bronchoscopy at the end for bronchial toilet, wash out the pleural cavity, and do a nerve block. Always put an ICC too.
• Complications
  • Hardware failure
  • Pain
  • Infection 3.1%