|Year : 2016 | Volume
| Issue : 2 | Page : 43-48
Surgical stabilization of blunt traumatic chest wall bony injuries
Jonathan Nwiloh1, Mark Walker2, Michael Nwiloh3
1 Department of Surgery, Atlanta Medical Center, Atlanta, USA
2 Surgical Health Collective, Atlanta, USA
3 Mercer University School of Medicine, Macon, GA, USA
|Date of Web Publication||16-Dec-2016|
Department of Surgery, Atlanta Medical Center, Atlanta, GA
Source of Support: None, Conflict of Interest: None
Objectives: Conservative management of rib fractures has been the standard of care. Recently, surgical fixation with rib plating is emerging as a superior option for flail chest (FC) and multiple rib fractures. This review details our experience with surgical fixation. Materials and Methods: The medical records of 18 patients with severe chest wall injuries referred to the cardiothoracic surgery service at a level 1 trauma center from January 2010 to December 2015 were retrospectively reviewed. 66.7% were male, mean age 58.4 ± 14.5, Glasgow Coma Score 13.3 ± 3.3, and injury severity score 20.4 ± 11.7. 77.8% (14/18) had multiple rib fractures, half with FC, 22.2% (4/18) sternal fractures, and 61.1% of patients were involved in motor vehicle accident. All patients underwent surgical stabilization except three with isolated sternal fractures treated conservatively. Results: 3.4 ± 0.5 ribs were plated in FC versus 2.4 ± 0.5 in non-FC patients. 64.2% had concomitant decortication and 7.1% lung wedge resection. All FC patients had severe lung contusion and respiratory failure requiring preoperative mechanical ventilation mean 10.7 ± 7.9 days. Postoperative ventilatory support was 7.4 ± 4.9 days in FC versus <24 h in non-FC patients. 57.1% of FC patients required tracheostomy for prolonged intubation. Mean interval to surgery, Intensive Care Unit, and hospital length of stay (LOS) was 13.3 ± 5.3, 22.4 ± 14.9, and 29.7 ± 9.2 in FC versus 5.3 ± 3.8, 10.3 ± 10.4, and 14.3 ± 9.3 days, respectively, in non-FC patients. 85.7% received blood transfusion, mean 5.7 ± 3.7 in FC versus 42.8% mean 3.7 ± 0.6 units in non-FC patients. Morbidity in FC patients were pneumonia 42.8%, empyema 14.2%, ARDS 14.2%, and acute kidney injury (AKI) 14.2% compared to non-FC patients AKI 25.0% and empyema 12.5%. There were no deaths. Conclusions: Rib plating of complicated chest wall injuries may reduce morbidity, hospital LOS, chronic disability, and should be considered in FC and multiple rib fractures.
Keywords: Blunt trauma, plating, rib fractures
|How to cite this article:|
Nwiloh J, Walker M, Nwiloh M. Surgical stabilization of blunt traumatic chest wall bony injuries. Niger J Cardiovasc Thorac Surg 2016;1:43-8
| Introduction|| |
Chest wall injuries are common, following blunt trauma, and the associated complications account for about 25% of deaths in these patients.  Flail chest (FC) or multiple rib fractures following blunt chest trauma can result in serious impairment of respiratory mechanics with resultant respiratory failure, pulmonary complications, and long-term disability if inadequately treated. In recent years, there has been renewed interest with a paradigm shift in the use of surgical stabilization devices in an attempt to reduce these acute and chronic complications.
| Materials and Methods|| |
Eighteen patients with severe chest wall injuries following blunt trauma were referred to the cardiothoracic surgery service at an urban level 1 trauma center from January 2010 to December 2015. They consisted of 12 (66.7%) males and 6 (33.3%) females, mean age 58.4 ± 14.5, range 39-88 years. Fourteen (77.8%) were caucasians and 4 (22.2%) African Americans. Glasgow Coma Score was 13.3 ± 3.3 and injury severity scale score (ISS) 20.4 ± 11.7. Motor vehicle accidents (MVA) accounted for 61.1% of the cases. The baseline patient demographics and preoperative variables are summarized in [Table 1]. Fourteen (77.8%) patients had multiple rib fractures with a mean of 5.6 ± 2.4 and 4 (22.2%) sternal fractures. Three patients with isolated sternal fractures were managed nonoperatively and were excluded from further analysis. Seven (46.6%) out of the remaining 15 patients had FC mean 3.4 ± 0.5 flail ribs, with chest wall instability [Figure 1]. All patients with FC suffered severe lung contusion complicated by respiratory failure requiring mechanical ventilatory support. Two patients were intubated by the emergency medical service personnel enroute to the hospital, three on arrival in the emergency room trauma bay, and the other two patients a few days after hospitalization. The mean duration of preoperative ventilatory support in the FC patients was 10.7 ± 7.9 days. Only one patient in the non-FC cohort was intubated preoperatively during advanced cardiopulmonary resuscitation for cardiac arrest secondary to massive bilateral pulmonary embolus. The indications for surgery in all patients were either respiratory failure and inability to wean from the ventilator, multiple rib fractures with severe pain despite analgesics or rib displacement with impaction in underlying lung. Pain control strategy used was a combination of narcotic patient controlled analgesia, intermittent intravenous or oral narcotics, intravenous or oral anti-inflammatory analgesics, and muscle relaxants. Surgery for operative reduction and fixation of ribs was performed through a limited posterolateral thoracotomy dividing usually only the latissimus dorsi muscle [Figure 2]. Because most patients were operated on over a week from time of injury, there were usually inflammatory changes and early callus formation at the fracture sites. This usually required mobilization, elevation, and realignment of displaced ribs before plating. Patients with retained clotted hemothorax were evacuated either through a video-assisted thoracoscopy (VATS) or open approach in patients with significant peel and trapped lung. The only sternal patient with surgical fixation had 1.6 cm distraction of the sternomanubrial joint, separation of costochondral junction of both 1 st rib and bilateral 2 nd rib fractures [Figure 3]. Fixation devices used were RibLoc rib fracture plating system by Acute Innovations, Hillsboro, OR, USA, and MatrixRib fixation system by Synthes CMF, West Chester, PA, USA. All data were entered into an Excel spreadsheet and then imported into Sigma Plot (Systat Software, Inc., San Jose, CA, USA) for statistical analysis. Categorical variables were reported as frequencies and percentages while continuous variables were reported as median, mean ± standard deviations. Univariate analysis by unpaired Student's t-test with two-tailed distribution was used for continuous variables and Chi-square test or Fisher's exact test used for categorical variables. P < 0.05 was considered statistically significant. Operative mortality was regarded as death within 30 days of surgery or during the same hospitalization.
| Results|| |
Fourteen patients with multiple rib fractures all underwent surgical fixation with plating using the MatrixRib in 9 (64.3%) and RibLoc in 5 (35.7%). The choice of stabilization device used was at the discretion of the surgeon although later years was mainly MatrixRib as this was thought to be easier to implant [Figure 4] and [Figure 5]. The seven patients with FC had 4.1 ± 1.0 flail ribs and had plating of 3.4 ± 0.5 ribs each, while the group without flail had 3.4 ± 1.6 fractured ribs with plating of 2.4 ± 0.5 ribs. Two of three patients with clavicle fracture also had operative fixation and plating at the same setting [Figure 6]. Two other patients had fixation of mandibular and pelvic fractures by plastic and orthopedic surgeons, respectively, at different settings. Nine (64.2%) of the 14 patients had decortication through a thoracotomy with the exception of one through VATS who also had a wedge resection of an injured lung. Two patients undergoing decortication had methicillin-sensitive Staphylococcus aureus empyema treated in addition with intravenous antibiotics. Four (57.1%) patients with FC required tracheostomy for prolonged intubation, three of whom had pneumonia, one adult respiratory distress syndrome (ARDS), and one acute kidney injury (AKI) that resolved without requiring dialysis [Table 2]. Three of the tracheostomy patients were discharged to long-term acute care (LTAC) and one was discharged home after decannulation. Two (28.5%) of 7 non-FC patients developed AKI but only one needed short-term hemodialysis. This patient had history of a hematologic malignancy and presented with cardiac arrest from massive pulmonary embolism treated with tissue plasminogen activator (tPA). He subsequently developed massive hemothorax from multiple broken ribs sustained during chest compression. In the non-FC cohort, one patient each went to LTAC and acute rehabilitation center and the remaining were discharged home. Blood transfusion was required in 85.7% of FC, mean 5.7 ± 3.7, and 42.8% of non-FC patients mean 3.7 ± 0.6 units. This was exclusive of an outlier the non-FC patient with hematologic malignancy, severe anemia, and idiopathic thrombocytopenia treated with tPA who received 13 units of packed red cells. The mean duration on ventilator, Intensive Care Unit (ICU), and hospital length of stay (LOS) and other indices are summarized in [Table 3]. There was no mortality in the series. One (7.1%) patient with plating of a clavicle fracture had the plate explanted 1 year later due to discomfort from clothing and car seat belt rubbing on the hardware.
| Discussion|| |
Rib fractures account for majority of blunt traumatic thoracic injuries which are predominantly sustained, following motor vehicle accidents (MVAs) and falls from heights. Rib fractures account for about 10% of patients admitted to trauma centers and roughly 10% of these have FC injuries.  FC, is generally defined as the fracture of 3 or more consecutive ribs in at least two locations, and results from transmission of severe kinetic energy to the chest wall and underlying intrathoracic organs. A large percentage of patients with FC, therefore, have some degree of underlying pulmonary contusion often resulting in respiratory insufficiency requiring mechanical ventilatory support. The majority of patients with blunt traumatic thoracic injuries can be effectively treated conservatively with analgesics, aggressive pulmonary toilet, and thoracostomy tubes for pneumothorax/hemothorax. Traditionally, most patients with FC and respiratory failure have been treated nonoperatively with positive pressure ventilation and with reported mortality ranging from 10% to 36%, most of which are attributed to associated injuries.  However, in recent years with advances in newer generation of rib fixation devices, there has been a resurgence in surgical stabilization of rib fractures in the hope of reducing mortality, morbidity, and chronic disability. The newer titanium plates have been designed to conform to the anatomy of the human ribs and are, therefore, easier to implant. Previous devices were not specific and the extended surgical incisions required were also associated with significant patient discomfort and morbidity. However, in spite of this paradigm shift, the role of surgical fixation for FC and multiple rib fractures remains controversial in the absence of any large prospective randomized trial (PRT) to show significant benefit over traditional nonoperative management. A definitive answer can only be obtained through large multicenter PRT, which would enable enrollment of enough patients with the statistical power to demonstrate any significant difference between the two treatment strategies. In the absence of such a study, recommendations and guidelines have been based on small single-institutional PRTs and small retrospective reviews. Tanaka et al.  in a PRT of 18 FC patients treated surgically and 19 treated nonoperatively found lower days on ventilator, ICU LOS, pneumonia, and cost in the surgical cohort. Similarly, Marasco et al.  in their PRT of 23 FC patients treated surgically compared to 23 treated conservatively observed significantly lower ICU LOS and duration of ventilation support. Another PRT by Granetzny et al.  of 20 FC patients treated surgically versus 20 treated conservatively again found significantly lower duration on ventilator, ICU LOS, and less restrictive pattern on pulmonary function tests at 2 months. The total number in these 3 published single-institutional PRTs ,, is still very small with only 61 FC patients treated surgically versus 62 FC conservatively. Against surgical fixation, on the other hand, is a retrospective review from 2 major Canadian trauma centers comparing 19 FC patients treated surgically to a matched 36 patients treated nonoperatively which observed no difference in outcome and, therefore, found no basis to justify operative fixation over conservative strategy. Again, this study is highly limited by being retrospective with very small numbers. In the absence of any published large PRTs, the Eastern Association for the Surgery of Trauma practice management guidelines gives a level 3 recommendation (based mainly on retrospective data) for surgical fixation of FC in patients with failure to wean from ventilator or when thoracotomy is required for other reasons.  It is obvious that the role of operative fixation, its indication and timing in FC and multiple rib fractures is still evolving. This will likely continue until more definitive answers can be obtained from large multi-institutional PRTs. Another reason for reservation and hesitation among some physicians is the additional cost implications of plating in the absence of definitive scientific proof of benefit. To address this cost consideration, Bhatnagar et al.  in their review using data from the National Trauma Data Bank and 2010 National Medicare reimbursement rates showed rib plating was more cost effective with an overall lower hospital cost compared to traditional nonoperative management of FC patients. In view of these unresolved controversies, many patients with FC and multiple rib fractures continue to be managed in most centers with the traditional nonoperative strategies including thoracic epidural, intercostals nerve blocks or patient controlled analgesia, aggressive chest physiotherapy, and ventilatory support for respiratory failure. This approach is not unreasonable, and based on currently available evidence, not all patients with FC or multiple rib fractures will require surgical fixation. This technique should probably be reserved for complicated cases with respiratory failure and inability to wean from ventilator, as well as chest wall deformities with refractory pain. Surgery should be deferred in ventilated patients with lung contusion and severe hypoxia and only considered if patient still unable to wean from the ventilator after resolution of lung contusion. Our patients with multiple rib fractures needed thoracic surgery for fracture instability, intractable pain, residual hemothorax or other thoracic injuries. The other consideration for reluctance recommending rib plating is the requirement for a thoracotomy which adds morbidity to the patients, especially in the current era of minimally invasive surgical approaches. In an attempt to mitigate against this, we use only one incision and limit the extent of the thoracic incision as much as possible to allow plating. CT scan with three-dimensional reconstruction can be helpful with preoperative planning of the surgical incision. We do not make any aggressive attempt to reach the higher 3 rd and 4 th ribs because this often may require extending the incision further posteriorly between the scapula and thoracic spine. This extension and vigorous lifting of the scapula as advocated by some to plate these high ribs may result in chronic shoulder joint discomfort and disability. Often, patients with these higher rib fractures also have associated scapular fractures. In less muscular individuals, the 4 th rib can be reached through our limited incision for plating without aggressive lifting of the scapular from the chest wall. With these considerations, we have not made attempts to reach the 3 rd and sometimes even the 4 th ribs when several lower ribs are involved in the flail segments. Plating only the involved lower contiguous ribs usually fixes the chest wall instability. Moreover, the higher 3 rd and 4 th ribs are also protected by the scapula. With regard to timing of surgery, some trauma centers have developed protocols (University of Florida, Gainesville) to intervene earlier with the belief that the optimal time for plating is within the first 48 h to avoid complications such as pneumonia. Others, however, suggest operating early only in FC without pulmonary contusion and to defer plating in patients with pulmonary contusion who remain ventilatory-dependent after resolution.  There is currently no guideline protocol at our institution and we have generally waited to allow stabilization of these patients with FC who often have pulmonary contusion and other associated multiple injuries. Therefore, in the absence of a protocol, patients have been referred to our service after this initial period of conservative management and trial of ventilator weaning. The mean interval from injury to surgery in our FC patients was 13.3 days and for non-FC cohort 5.3 days. One disadvantage of waiting however is that often the ribs may already have started healing in their displaced positions and, therefore, requires mobilization for proper realignment before plating. This is usually not difficult to achieve but can sometimes result in a little more bleeding than usual. Our FC patients had a significantly higher ISS score, higher frequency of blood transfusion, and number of packed red blood cells (PRBCs) units administered compared to the non-FC patients. ARDS occurred only in one FC patient who received 6 PRBC units, while 2 other FC patients transfused 7 and 12 PRBC units, respectively, did not develop ARDS. As with most other reported FC studies, pneumonia was the most common complication, followed by empyema and AKI. Two patients with multiple rib fractures also developed AKI with one needing short-term hemodialysis. There was no mortality in our series. Although we did not compare surgically treated patients to a matched conservatively treated cohort, based on our clinical observations, we agree with other authors that rib plating may be beneficial in select group of patients with complicated FC and multiple rib fractures meeting the earlier enumerated criteria. While there are different fixation devices available in America, Europe, and Asia, they are presently unavailable in most of Africa. The reasons perhaps for their limited availability in Africa may include the increased cost associated with surgical plating and lack of physicians' awareness of potential benefits of rib plating. To enable wider utilization of these plating devices in resource-poor countries seen in most of Africa, may require the manufacturers to have special pricing concession for the region as has been done with other medical devices. In four blunt chest trauma reviews from South Africa, Nigeria, Cameroun totaling 1670 patients, MVA accounted for 78%-98% of cases with rib fractures occurring in 42%-57% and FC seen in 3%-26% of patients. None of the reported FC patients were treated with surgical fixation, and mortality and morbidity were not specified for this group in any of the reviews. ,,, Since trauma, especially MVA, has become a major cause of death and disability in Africa and other Third World countries, increasing numbers of multiple rib fractures and FC are likely to be encountered and some can definitely benefit from surgical stabilization with plating if locally available.
| Conclusions|| |
This review although limited by small numbers and its retrospective nature, supports a growing consensus that operative fixation of complex chest wall injuries may result in a reduction in progression of respiratory complications and shortened hospital stay.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma 1994;37:975-9.
Smith S, Asensio J. Operative treatment of chest wall injuries. In: Asensio J, Trunkey D, editor. Current Therapy of Trauma and Surgical Critical Care. Philadelphia: Elsevier Saunders; 2016.
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 2002;52:727-32.
Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al.
Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013;216:924-32.
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 2005;4:583-7.
Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward T 3rd, 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 2012;73(5 Suppl 4):S351-61.
Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: What is the benefit? J Am Coll Surg 2012;215:201-5.
Roux P, Fisher RM. Chest injuries in children: An analysis of 100 cases of blunt chest trauma from motor vehicle accidents. J Pediatr Surg 1992;27:551-5.
Skinner DL, den Hollander D, Laing GL, Rodseth RN, Muckart DJ. Severe blunt thoracic trauma: Differences between adults and children in a level I trauma centre. S Afr Med J 2015;105:47-51.
Thomas MO, Ogunleye EO. Etiopathology and management challenges of blunt chest trauma in Nigeria. Asian Cardiovasc Thorac Ann 2009;17:608-11.
Mefire AC, Pagbe JJ, Fokou M, Nguimbous JF, Guifo ML, Bahebeck J. Analysis of epidemiology, lesions, treatment and outcome of 354 consecutive cases of blunt and penetrating trauma to the chest in an African setting. S Afr J Surg 2010;48:90-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]