RIB FIXATION VERSUS CONSERVATIVE MANAGEMENT OF RIB FRACTURES IN TRAUMA PATIENTS
AbstractBackground: 10–15 % of trauma patient have chest injuries. There is a paradigm shift in the last two decades towards rib fixation from conservative management. Rib fixation results in immediate pain reduction in patients. Although rib fixation shows promising results, conservative management is still preferred. Methods: The study was carried out in CMH Lahore from Jan 2017 to March 2018. It was a Controlled Prospective study. Convenient sampling was used. 43 patients are included in the study. Patients with four or more fracture ribs were included. Patients followed at one, two and three months with spirometery/X-ray /clinical response. Rib fixation was done in 21 patients while 22 were managed conservatively. Patients were given choice of both the management options and treated as per their choice resulting in two groups. Results: Mean age of patients is 51.35 years. Majority of them were males (86.05%), had haemothorax as confirmed with CT scan (69.80%) and unilateral fracture (79.10%). 7.40% have flail segment. Operative group shows statistically significant improvement in the recovery to work and less post operative pain when compared to control group. There were no statistical differences among variables such as pre-operative severity and pain index, length of hospital stay, number of days for ventilator support and post op FEV1. There is statistically significant reduction in pneumonia (p <0.05), Acquired respiratory distress syndrome (ARDS) (p <0.05), ventilatory support greater than 1 day (p < 0.05) but there is no statistically significant reduction in Conclusion: Rib fixation should be performed early after trauma as it decreases pain, lessens complications and facilitate early recovery to work .Keywords: Rib fractures; titanium plates; fixation; trauma
Gotta AW. Trauma: The unrecognized epidemic. Anesthesiol Clin. Elsevier; 1996;14(1):1–12.
Micheal Redies (AO Education,Davos S. The global trauma epidemic. AO Dialogue [Internet]. 2009;20–1. Available from: https://www.aofoundation.org/Structure/the-ao.../Dialogue/AODialogue_2009_02.pdf
Demirhan R, Onan B, Oz K, Halezeroglu S. Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience☆. Interact Cardiovasc Thorac Surg. 2009 Sep;9(3):450–3.
Organization WH. The global burden of disease: 2004 update. Geneva: World Health Organization; 2008. 2010.
Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward III T, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. LWW; 2012;73(5):S351–61.
Insertion of metal rib reinforcements to stabilise a flail chest wall [Internet]. 2010. Available from: https://www.nice.org.uk/guidance/ipg361/chapter/1-Guidance
SURGICAL FIXATION OF RIB FRACTURES [Internet]. 2013. Available from: http://www.surgicalcriticalcare.net/Guidelines/Surgical Fixation of Rib Fractures 2013.pdf
Chen J, Jeremitsky E, Philp F, Fry W, Smith RS. A chest trauma scoring system to predict outcomes. Surgery. Elsevier; 2014;156(4):988–94.
Nirula R, Diaz JJ, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg. Springer; 2009;33(1):14–22.
Jiménez-Quijano A, Varón-Cotés JC, García-Herreros-Hellal LG, Espinosa-Moya B, Rivero-Rapalino O, Salazar-Marulanda M. Rib cage ostheosynthesis. Literature review and case reports. Cirugía y Cir (English Ed. Elsevier; 2015;83(4):339–44.
Bemelman M, Poeze M, Blokhuis TJ, Leenen LPH. Historic overview of treatment techniques for rib fractures and flail chest. Eur J trauma Emerg Surg. Springer; 2010;36(5):407–15.
Avery EE, Mörch ET, Head JR, Benson DW. Severe crushing injuries of the chest; a new method of treatment with continuous hyperventilation by means of intermittent positive endotracheal insufflation. Q Bull Northwest Univ Med Sch. Northwestern University Feinberg School of Medicine; 1955;29(4):301.
Heroy WW, Eggleston FC. A method of skeletal traction applied through the sternum in “steering wheel” injury of the chest. Ann Surg. Lippincott, Williams, and Wilkins; 1951;133(1):135.
Berry FB. The treatment of injuries to the chest. Am J Surg. Elsevier; 1941;54(1):280–8.
DeBakey M. The management of chest wounds. Coll Rev Int Abst Surg. 1942;74:203–37.
Hagen K. Multiple rib fractures treated with a drinker respirator: a case report. JBJS. LWW; 1945;27(2):330–4.
Elkin DC, Cooper F. Thoracic injuries: review of cases. Surg Gynec Obs. 1943;72:271.
Sillar W. The crushed chest: Management of the flail anterior segment. J Bone Joint Surg Br. The British Editorial Society of Bone and Joint Surgery; 1961;43(4):738–45.
Labitzke R, Schmit-Neuerburg K, Schramm G. Indikation zur Thoracotomie und Rippenstabilisierung beim Thoraxtrauma im hohen Lebensalter. Chirurg. 1980;51:576–80.
Paris F, Tarazona V, Blasco E, Canto A, Casillas M, Pastor J, et al. Surgical stabilization of traumatic flail chest. Thorax. BMJ Publishing Group Ltd; 1975;30(5):521–7.
Judet R. Costal osteosynthesis. Rev Chir Orthop Reparatrice Appar Mot. 1973;59:Suppl-1.
Sanchez-Lloret J, Letang E, Mateu M, Callejas MA, Catalan M, Canalis E, et al. Indications and surgical treatment of the traumatic flail chest syndrome. An original technique. Thorac Cardiovasc Surg. © Georg Thieme Verlag Stuttgart· New York; 1982;30(05):294–7.
Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. European Association for Cardio-Thoracic Surgery; 2005;4(6):583–7.
Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis. Ann Surg. NIH Public Access; 2013;258(6).
Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma Acute Care Surg. LWW; 2002;52(4):727–32.
Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, SCHMIT-NEUERBURG P. Behandlungsergebnisse der operativen thoraxwandstabilisierung bei instabilem thorax mit und ohne lungenkontusion. Unfallchirurg. Springer; 1996;99(6):425–34.
Sarani B (George WU. Indications for Operative Rib Fixation.
Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma Acute Care Surg. LWW; 2000;48(6):1040–7.
Jones KM, Reed RL, Luchette FA. The ribs or not the ribs: which influences mortality? Am J Surg. Elsevier; 2011;202(5):598–604.
Khandelwal G, Mathur RK, Shukla S, Maheshwari A. A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture. Int J Surg. Elsevier; 2011;9(6):478–81.
Sarıtaş A, Güneren G, Sarıtaş PU, Kızılkaya SA, Ugış C. The Decrease of the Duration of Stay in the ICU with Rib Fixation in a Case of Multiple Rib Fracture. Turkish J Anaesthesiol Reanim. Turkish Society of Anaesthesiology and Reanimation; 2014;42(5):277.
Jones TB, Richardson EP. Traction on the sternum in the treatment of multiple fractured ribs. Surg Gynecol Obs. 1926;42(42):283–5.
Jaslow IA. Skeletal traction in the treatment of multiple fractures of the thoracic cage. Am J Surg. Elsevier; 1946;72(5):753–5.
Williams MH. Severe Crushing Injury to the Chest: Report of a Case having Extensive Bilateral Rib Fractures Successfully Treated by Pericostal Skeletal Traction. Ann Surg. Lippincott, Williams, and Wilkins; 1948;128(5):1006.
Schrire T. Control of the Crushed Chest: The Use of the “Cape Town Limpet.” Dis Chest. Elsevier; 1963;44(2):141–5.