Adam M. Shiroff, Jane Keating, J. R. Milanez de Campos, Thomas W. White
Multiple rib fractures from trauma are common and nonoperative management, including pain control and aggressive pulmonary care, are the mainstay of treatment. However, patients with hindered pulmonary function despite maximal medical therapy, either from acute pain or chest wall instability (flail chest) should be considered for surgical rib stabilization. Additionally, patients with persistent pain or with rib fractures that do not heal (nonunion) should also be considered for surgery. Indications, contraindications, surgical considerations, complications, and future directions of surgical stabilization of rib fractures are reviewed here.
{"title":"Surgical stabilization of rib fractures","authors":"Adam M. Shiroff, Jane Keating, J. R. Milanez de Campos, Thomas W. White","doi":"10.4103/jctt.jctt_19_19","DOIUrl":"https://doi.org/10.4103/jctt.jctt_19_19","url":null,"abstract":"Multiple rib fractures from trauma are common and nonoperative management, including pain control and aggressive pulmonary care, are the mainstay of treatment. However, patients with hindered pulmonary function despite maximal medical therapy, either from acute pain or chest wall instability (flail chest) should be considered for surgical rib stabilization. Additionally, patients with persistent pain or with rib fractures that do not heal (nonunion) should also be considered for surgery. Indications, contraindications, surgical considerations, complications, and future directions of surgical stabilization of rib fractures are reviewed here.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"4 1","pages":"41 - 47"},"PeriodicalIF":0.0,"publicationDate":"2019-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70787651","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Walker, Sean M. Mitchell, Pierce Johnson, Joshua W. Hustedt, N. Dehghan, M. McKee, Clifford B. Jones
Background: Flail chest injuries typically occur in poly-traumatized patients and are often associated with prolonged hospital stays and high rates of morbidity and mortality. Despite multiple studies showing significantly improved outcomes with surgical fixation, the surgical community has been slow to adopt rib fixation as a part of practice and, as a result, many of these patients never undergo surgical fixation. Purpose: The purpose of this study is to determine the percentage of flail chest injuries that are being treated with surgical fixation in the United States. In addition, a survey of orthopedic trauma surgeons was conducted to assess their perception of the role of orthopedics in the treatment of patients with flail chest injuries. Methods: Patients diagnosed with a flail chest injury were identified using the National Inpatient Sample (NIS) database between 2001 and 2012 and divided into two groups based on whether or not surgical fixation of the chest wall was performed. In addition, we distributed a survey questionnaire to orthopedic trauma surgeons focusing on each individual's experience with rib fracture fixation both in training and practice. Results: A total of 45,202 patients with a flail chest injury were identified using the NIS database between 2001 and 2012. Of these, 2.1% underwent surgical fixation of the chest wall with an increase in rate of fixation from 0.8% to 3.3% over the study period. According to our survey, only 20% of orthopedic trauma surgeons performed any rib fracture fixation cases in training, and only 24% perform rib fracture fixation cases in their practice. Of those who do not perform rib fracture fixation, 72% would consider doing so if they received additional training on the topic. Of all participants surveyed, 60% believed that rib fracture fixation should be a part of the orthopedic residency curriculum and 89% believed that it should be a part of the orthopedic trauma fellowship curriculum. Conclusions: Very few flail chest injuries are being treated with surgical fixation despite the emerging literature showing improved outcomes when compared to nonoperative management. Our survey shows that there is significant interest in incorporating rib fracture fixation into surgeons' training curriculum, as well as providing specialized workshops for practicing surgeons. We hope this work encourages the surgical community to embrace rib fracture fixation as a part of our specialty so that patients with flail chest injuries receive optimal care.
{"title":"Current trends in the management of flail chest and the perceived role of the surgeon","authors":"J. Walker, Sean M. Mitchell, Pierce Johnson, Joshua W. Hustedt, N. Dehghan, M. McKee, Clifford B. Jones","doi":"10.4103/jctt.jctt_2_19","DOIUrl":"https://doi.org/10.4103/jctt.jctt_2_19","url":null,"abstract":"Background: Flail chest injuries typically occur in poly-traumatized patients and are often associated with prolonged hospital stays and high rates of morbidity and mortality. Despite multiple studies showing significantly improved outcomes with surgical fixation, the surgical community has been slow to adopt rib fixation as a part of practice and, as a result, many of these patients never undergo surgical fixation. Purpose: The purpose of this study is to determine the percentage of flail chest injuries that are being treated with surgical fixation in the United States. In addition, a survey of orthopedic trauma surgeons was conducted to assess their perception of the role of orthopedics in the treatment of patients with flail chest injuries. Methods: Patients diagnosed with a flail chest injury were identified using the National Inpatient Sample (NIS) database between 2001 and 2012 and divided into two groups based on whether or not surgical fixation of the chest wall was performed. In addition, we distributed a survey questionnaire to orthopedic trauma surgeons focusing on each individual's experience with rib fracture fixation both in training and practice. Results: A total of 45,202 patients with a flail chest injury were identified using the NIS database between 2001 and 2012. Of these, 2.1% underwent surgical fixation of the chest wall with an increase in rate of fixation from 0.8% to 3.3% over the study period. According to our survey, only 20% of orthopedic trauma surgeons performed any rib fracture fixation cases in training, and only 24% perform rib fracture fixation cases in their practice. Of those who do not perform rib fracture fixation, 72% would consider doing so if they received additional training on the topic. Of all participants surveyed, 60% believed that rib fracture fixation should be a part of the orthopedic residency curriculum and 89% believed that it should be a part of the orthopedic trauma fellowship curriculum. Conclusions: Very few flail chest injuries are being treated with surgical fixation despite the emerging literature showing improved outcomes when compared to nonoperative management. Our survey shows that there is significant interest in incorporating rib fracture fixation into surgeons' training curriculum, as well as providing specialized workshops for practicing surgeons. We hope this work encourages the surgical community to embrace rib fracture fixation as a part of our specialty so that patients with flail chest injuries receive optimal care.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"12 1","pages":"4 - 9"},"PeriodicalIF":0.0,"publicationDate":"2019-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70787861","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Surgical rib fixation in displaced rib fracture has been associated with positive patient outcomes in the literature. There is no data in the literature detailing the volume related outcomes in centres that offer surgical rib fixation in these patients. Methods: A retrospective review was conducted on surgical rib fixation cases performed from 2014 to 2018, with the early phase (EP) consisting of cases performed in the 2014-2017 period and the recent phase (RP) consisting of cases performed in 2018 to date. Variables for comparison included, indication for intervention, pain outcomes, and length of stay (LOS). Results: The five-year period yielded 37 cases. In the EP, 17 cases were performed, compared to 20 cases in the RP. The chest AIS scores were >3 for all cases with an average ISS of 21 in the EP compared to 19 in the RP. All patients underwent surgical rib fixation within 96 hours of admission. Pain was the predominant indication for intervention in the EP (65%, n = 11) compared to the RP where deformity and respiratory support (55%, n = 11) were the chief indicators. Subjective pain improvement was in favour of RP by 2.5 days. The average LOS was 546 hours days in the EP group, and 391 hours in the RP group. More anatomically difficult posterior and bilateral rib fixation cases were carried out in the RP group. Follow-up rate between the EP and RP were 75% vs 85% respectively with no hardware or pulmonary complications. Conclusion: Preliminary data analysis from the authors' institution suggests surgical rib fixation can be conducted with minimal complication. Increased case volume might improve outcomes related to subjective pain scores, length of stay, and complexity of surgical technique.
{"title":"Surgical rib fixation: Does increase case volume lead to improved outcomes?","authors":"B. Patel, Gary L. Hung, M. Wullschleger","doi":"10.4103/jctt.jctt_4_19","DOIUrl":"https://doi.org/10.4103/jctt.jctt_4_19","url":null,"abstract":"Background: Surgical rib fixation in displaced rib fracture has been associated with positive patient outcomes in the literature. There is no data in the literature detailing the volume related outcomes in centres that offer surgical rib fixation in these patients. Methods: A retrospective review was conducted on surgical rib fixation cases performed from 2014 to 2018, with the early phase (EP) consisting of cases performed in the 2014-2017 period and the recent phase (RP) consisting of cases performed in 2018 to date. Variables for comparison included, indication for intervention, pain outcomes, and length of stay (LOS). Results: The five-year period yielded 37 cases. In the EP, 17 cases were performed, compared to 20 cases in the RP. The chest AIS scores were >3 for all cases with an average ISS of 21 in the EP compared to 19 in the RP. All patients underwent surgical rib fixation within 96 hours of admission. Pain was the predominant indication for intervention in the EP (65%, n = 11) compared to the RP where deformity and respiratory support (55%, n = 11) were the chief indicators. Subjective pain improvement was in favour of RP by 2.5 days. The average LOS was 546 hours days in the EP group, and 391 hours in the RP group. More anatomically difficult posterior and bilateral rib fixation cases were carried out in the RP group. Follow-up rate between the EP and RP were 75% vs 85% respectively with no hardware or pulmonary complications. Conclusion: Preliminary data analysis from the authors' institution suggests surgical rib fixation can be conducted with minimal complication. Increased case volume might improve outcomes related to subjective pain scores, length of stay, and complexity of surgical technique.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"4 1","pages":"10 - 13"},"PeriodicalIF":0.0,"publicationDate":"2019-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70788222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A 72-year-old male with a history of atrial fibrillation, remote stroke, hypertension, and chronic obstructive pulmonary disease presented following a high-speed motor vehicle collision. Injuries included bilateral segmental rib fractures with radiographic anterior flail and a right acetabular fracture. Secondary to thoracic trauma, mechanical ventilation was required and the patient underwent surgical stabilization of left-sided fractures utilizing by 75, 75, 115, and 50 mm plates for ribs 3, 4, 5, and 6, respectively, early in his hospital course followed by fixation of the right hemipelvis. A trial of extubation was unsuccessful. During reintubation, he developed marked abdominal distension and large volume pneumoperitoneum with signs of compartment syndrome. Emergent decompressive laparotomy revealed a perforated posterior prepyloric gastric ulcer that was repaired. Intensive care unit course was complicated by 72 h of multisystem organ failure; however, he recovered and was again nearing the point of ventilator liberation. Right-sided rib stabilization, albeit it delayed, was performed with fixation of 3, 4, 5, and 6 accomplished with long-segment plates bridging to costal cartilage in order to achieve stability. Dense inflammation and callous formation were encountered prolonging operative time. Tracheostomy was performed 3 days postoperatively, despite minimal ventilator requirements, given ongoing secretions and development of pseudomonal pneumonia. The patient was weaned to tracheostomy collar with in-line speaking valve within 2 weeks. This case highlights surgical rib stabilization in a frail, multiply injured patient through which ventilator wean was expedited and rehabilitation potential was optimized.
{"title":"To fix or not to fix: Delayed repair of anterior flail in the frail and multiply injured","authors":"Brian Dusseau, B. Goslin, William B. DeVoe","doi":"10.4103/jctt.jctt_7_19","DOIUrl":"https://doi.org/10.4103/jctt.jctt_7_19","url":null,"abstract":"A 72-year-old male with a history of atrial fibrillation, remote stroke, hypertension, and chronic obstructive pulmonary disease presented following a high-speed motor vehicle collision. Injuries included bilateral segmental rib fractures with radiographic anterior flail and a right acetabular fracture. Secondary to thoracic trauma, mechanical ventilation was required and the patient underwent surgical stabilization of left-sided fractures utilizing by 75, 75, 115, and 50 mm plates for ribs 3, 4, 5, and 6, respectively, early in his hospital course followed by fixation of the right hemipelvis. A trial of extubation was unsuccessful. During reintubation, he developed marked abdominal distension and large volume pneumoperitoneum with signs of compartment syndrome. Emergent decompressive laparotomy revealed a perforated posterior prepyloric gastric ulcer that was repaired. Intensive care unit course was complicated by 72 h of multisystem organ failure; however, he recovered and was again nearing the point of ventilator liberation. Right-sided rib stabilization, albeit it delayed, was performed with fixation of 3, 4, 5, and 6 accomplished with long-segment plates bridging to costal cartilage in order to achieve stability. Dense inflammation and callous formation were encountered prolonging operative time. Tracheostomy was performed 3 days postoperatively, despite minimal ventilator requirements, given ongoing secretions and development of pseudomonal pneumonia. The patient was weaned to tracheostomy collar with in-line speaking valve within 2 weeks. This case highlights surgical rib stabilization in a frail, multiply injured patient through which ventilator wean was expedited and rehabilitation potential was optimized.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"4 1","pages":"49 - 51"},"PeriodicalIF":0.0,"publicationDate":"2019-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70788292","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Traumatic pulmonary hernia is a rare entity that often presents immediately after the trauma but may appear years after the incident. We report a case of a 53-year-old female with polytrauma including a traumatic pulmonary hernia following an all-terrain vehicle (ATV) rollover. Left pulmonary hernia reduction, rib plating, and pectoralis flap were performed. After the surgery, the patient's pain and respiratory status drastically improved, and the patient was able to leave the hospital without any supplemental oxygen requirements. Pulmonary hernia is a rare etiology seen in blunt traumas involving the chest. These often can be associated with rib fractures, pulmonary contusions, and clavicular fractures. There are multiple techniques for surgical repair including using autologous tissues, synthetic materials, and even minimally invasive techniques. Although pulmonary hernia is rare, every trauma and thoracic surgeon should be aware of the etiology of this condition and the options available for surgical repair.
{"title":"Traumatic lung herniation after ATV rollover","authors":"R. Kyriakakis, Geoffrey T. Lam, C. Valdez","doi":"10.4103/jctt.jctt_3_19","DOIUrl":"https://doi.org/10.4103/jctt.jctt_3_19","url":null,"abstract":"Traumatic pulmonary hernia is a rare entity that often presents immediately after the trauma but may appear years after the incident. We report a case of a 53-year-old female with polytrauma including a traumatic pulmonary hernia following an all-terrain vehicle (ATV) rollover. Left pulmonary hernia reduction, rib plating, and pectoralis flap were performed. After the surgery, the patient's pain and respiratory status drastically improved, and the patient was able to leave the hospital without any supplemental oxygen requirements. Pulmonary hernia is a rare etiology seen in blunt traumas involving the chest. These often can be associated with rib fractures, pulmonary contusions, and clavicular fractures. There are multiple techniques for surgical repair including using autologous tissues, synthetic materials, and even minimally invasive techniques. Although pulmonary hernia is rare, every trauma and thoracic surgeon should be aware of the etiology of this condition and the options available for surgical repair.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"4 1","pages":"63 - 65"},"PeriodicalIF":0.0,"publicationDate":"2019-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70788215","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Necessity is the mother of invention: Rib fixation with pediatric ankle plates and screws after successful thoracoabdominal damage control surgery","authors":"M. Rashid","doi":"10.4103/jctt.jctt_20_19","DOIUrl":"https://doi.org/10.4103/jctt.jctt_20_19","url":null,"abstract":"","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"4 1","pages":"1 - 2"},"PeriodicalIF":0.0,"publicationDate":"2019-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70787710","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
K. Wallwork, Jenny Mitchell, N. Rahman, E. Belcher
Context: Flail chest is associated with significant mortality risk. Chest wall repair is associated with improved outcomes; however, the optimal fixation technique is unknown. Aims: We undertook a review to assess the optimal fixation technique required in order to successfully repair flail chest. Subjects and Methods: This is a retrospective review of consecutive patients with multiple rib fractures undergoing surgical fixation. The predictive value of ratio of fractures fixed in relation to flail segment and ratio of ribs fixed in relation to flail segment was assessed by the primary outcome measure of requirement for reoperation. Results: Thirty-one patients presenting with symptomatic rib fractures were referred to a single surgeon for primary management or a second opinion following previous fixation, between August 2011 and October 2018, and underwent repair. Twenty-two patients were male (71%), and the median age was 66 years (range: 18–81). Twenty-seven patients (87%) were diagnosed with flail segment. Twenty-four patients had a “Fracture Fixation to Flail” ratio (Fx: Fl) ≥1, and none required further rib fixation, whereas three patients had Fx: Fl< 1, two of whom (67%) required further rib fixation (P = 0.0085). Twenty patients had Rx: Fl≥1, and none required further rib fixation, whereas seven patients had Rx: Fl< 1, in whom five (71%) required no further intervention and two (29%) required further rib fixation (P = 0.0598). Minimum fixation number (MFN) was calculated. MFN was achieved in 22 of 27 patients. Two of the four patients with MFN did not achieve the required refixation (P = 0.0171). Conclusions: Fx:Flmost accurately predicts the risk of underfixation and subsequent requirement for further intervention in patients undergoing operative repair of flail chest.
{"title":"What is the minimum fixation required to repair flail chest?","authors":"K. Wallwork, Jenny Mitchell, N. Rahman, E. Belcher","doi":"10.4103/jctt.jctt_5_19","DOIUrl":"https://doi.org/10.4103/jctt.jctt_5_19","url":null,"abstract":"Context: Flail chest is associated with significant mortality risk. Chest wall repair is associated with improved outcomes; however, the optimal fixation technique is unknown. Aims: We undertook a review to assess the optimal fixation technique required in order to successfully repair flail chest. Subjects and Methods: This is a retrospective review of consecutive patients with multiple rib fractures undergoing surgical fixation. The predictive value of ratio of fractures fixed in relation to flail segment and ratio of ribs fixed in relation to flail segment was assessed by the primary outcome measure of requirement for reoperation. Results: Thirty-one patients presenting with symptomatic rib fractures were referred to a single surgeon for primary management or a second opinion following previous fixation, between August 2011 and October 2018, and underwent repair. Twenty-two patients were male (71%), and the median age was 66 years (range: 18–81). Twenty-seven patients (87%) were diagnosed with flail segment. Twenty-four patients had a “Fracture Fixation to Flail” ratio (Fx: Fl) ≥1, and none required further rib fixation, whereas three patients had Fx: Fl< 1, two of whom (67%) required further rib fixation (P = 0.0085). Twenty patients had Rx: Fl≥1, and none required further rib fixation, whereas seven patients had Rx: Fl< 1, in whom five (71%) required no further intervention and two (29%) required further rib fixation (P = 0.0598). Minimum fixation number (MFN) was calculated. MFN was achieved in 22 of 27 patients. Two of the four patients with MFN did not achieve the required refixation (P = 0.0171). Conclusions: Fx:Flmost accurately predicts the risk of underfixation and subsequent requirement for further intervention in patients undergoing operative repair of flail chest.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"4 1","pages":"14 - 19"},"PeriodicalIF":0.0,"publicationDate":"2019-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70788239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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