Download Broken Ribs

Broken Ribs
When do we need to Fix them?
Richard A. Malthaner
MD MSc FRCSC FACS FCCP
Associate Professor
Division of Thoracic Surgery
LHSC Trauma Program
No Conflict of Interest
No Conflict of Interest
Broken rib threatens German
keeper's World Cup
BERLIN (AP) — Bayer Leverkusen says
Germany goalkeeper Rene Adler has
broken a rib and will miss a league match
this weekend.
Leverkusen said Tuesday that the 26year-old won't need an operation on the
injury, which he sustained in last
weekend's 2-1 loss at Stuttgart.
He will miss at least this weekend's home
Bundesliga match against Hannover.
Adler said he is "cautiously optimistic" of a
quick recovery.
Germany coach Joachim Loew has
installed Adler as his No. 1 goalkeeper
ahead of the World Cup in South Africa.
Amy Winehouse Goes To Hospital After
Bruising Ribs
In Celebs by Kristine Gasbarre , on Tuesday, April 27, 2010, 10:07 AM (PDT)
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Wino admitted to hospital with bruised ribs
and cut eye.
The biggest stories in Tuesday's news is
Amy Winehouse's fall at home, just a day
after word got out that she and ex-husband
Blake Fielder-Civil are planning a second
honeymoon together.
Twenty-six-year-old Amy Winehouse, who's
known for her drug and alcohol addictions,
was admitted to a London health clinic on
Tuesday after falling at home. It's not clear
what she was doing when she fell, who was
with her (we're curious about Blake in
particular) or whether substances were
involved, but reports state that she
sustained a bruised rib and a prominent cut
above her eye.
Outline
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Anatomy
Pathology
Etiology
Diagnosis
Treatment
Elderly
When to fix?
Trivia Quiz
RibsTake Home
• Rib fractures:
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Very common
Think about the inside
Marker for more serious injuries
Life threatening in elderly
Surgical fixation is promising
Pain control
Pain control
Question 1
• Men have more ribs than women.
• False
• Adam lost a rib to make Eve
• True.
• Men always eat more at the buffet. They are
bigger, so they have more ribs
• False
• Men are equal to women
Question 1
• Men have more ribs than women.
• False
• Adam lost a rib to make Eve
• True.
• Men always eat more at the buffet. They are
bigger, so they have more ribs
• False
• Men are equal to women
Anatomy 101
• Thorax
• Ribs
• Sternum
• Costal cartilage
Think Deep
What’s Inside
Types of Ribs
1st Rib
2nd Rib
Cervical Ribs
Spare Ribs
Question 2
• How many bones are
there in the human
body?
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12
1
206
300
Too many to count
Question 2
• How many bones are
there in the human
body?
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12
1
206
300
Too many to count
Etiology
• Most common:
• MVC
• Others:
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Falls
CPR
Blasts
Congenital
Classification
• Isolated rib fractures
• Think deep
• Flail Chest
• Complex and life threatening
Rib Fractures
• Fractures of 1st, 2nd
ribs require high force
• Frequently have injury
to lung, bronchi,
aorta, and great
vessels
• 30% will die
Rib Fractures
• Most commonly 5th to
9th ribs
• Upper ribs are
protected
• Lower ribs are
smaller, shorter and
mobile
• Floating ribs least
injured
Rib Fractures
• Fractures of 8th to
12th ribs can damage
underlying abdominal
solid organs:
• Liver
• Spleen
• Kidneys
• Diaphragm
Question 3
• What is the most fractured bone in
the body if you are older than 75?
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Ribs
Clavicle
Femur
Skull
Os penis
Question 3
• What is the most fractured bone in
the body if you are older than 75?
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Ribs
Clavicle
Femur
Skull
Os penis
Question 4
• What is the least fractured bone in the
chest?
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Sternum
Clavicle
Rib
Scapula
Os gladiolus
Question 4
• What is the least fractured bone in the
chest?
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Sternum
Clavicle
Rib
Scapula
Os gladiolus
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130 battle wounds
20% chest
Spears
Swords
Arrows
Stones
Ribs fractures not recorded
Modern Battlefield
Operation Iraqi Freedom
• Forward Army
Surgical Team
• March 21 2003 + 23
days
• 154 patients
• 52 E POWs
• 79 soldiers
• 23 Iraqi civilians
Ontario Trauma Registry
1994 – 1998
Cuccarolo G et al. 2006
13,335
ISS > 12, age > 16
5,233 93%
Blunt
5,655 42%
7,700 58%
Chest Trauma
No Chest Trauma
422 7%
Penetrating
Blunt Chest Trauma
Cuccarolo G et al. 2006
Chest Trauma in Ontario
1994 – 1998
Cuccarolo G et al. 2006
Esophagus
0.2%
1.4%
Lung
44%
37%
Ribs
74%
17%
Blunt
Penetrating
Trachea
0.5%
6%
Heart
8%
33%
Sternum
6%
1.4%
Diaphragm
4%
29%
Assessment
• History
• Inspection
• Asymmetric
breathing
• Pain with cough or
movement
• Chest wall
deformity (ribs)
• Bruising
Assessment
• Anterior-posterior
compression
• Transverse
compression
Muscle Contusions/Strains
• Internal/external intercostals injured
• Pain with active ROM, breathing,
coughing, sneezing
• No crepitus
• No compression tenderness
Isolated Rib fractures
• Localised pain, tenderness, crepitus
• Imaging to exclude other injuries
• CXR / CT
• Compression tenderness
• Don’t need rib views
• ? Bone scan
Costochondral
separation/subluxation
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Pain
Crepitus
Difficulty with breathing
Tenderness
Hooking maneuver
Poor healing
“Clicking rib syndrome”
“Slipping rib syndrome”
Thoracic AIS
AIS
Severity
Injury
1
Minor
Rib contusion, fracture, or both
2
Moderate
2-3 rib fractures, stable chest
Multiple fractures of a single rib
3
Severe, not life
threatening
Rib fracture: open, displace,
comminuted
< 3 rib fractures
4
Severe, life
threatening
Flail chest
5
Critical
Severe flail on ventilator
Rib Fractures
Ziegler DW and Agarwal NN. J Trauma 1994; 37: 975-979
• 7147 trauma
patients
• York, PA
• 10% rib fractures
• Morbidity and
mortality
increases with
each broken rib
Increased Disability
Landercasper J et al. J Trauma 1984; 24(5): 410
• 62 flails 1971 -1982
• 32 patients with 5 year mean follow-up
• only 43% return to full employment
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25% chest tightness
49% chest wall pain
38% change in activity level
28% significant dyspnea
Treatment
Isolated Rib Fractures
• Analgesia
• Deep breathing
and coughing
• Avoid taping /
bandaging /
splinting
Flail Chest
• Two or more
adjacent ribs in
two or more
places (ATLS)
• Free-floating
chest wall
segment
• Paradoxical
movement
Diagnosis
• Hypoxia
• Impaired ventilation
• Paradoxical chest
movement “flail”
• look and wait for it
• depends on patient’s
ability to splint
• Chest radiograph
• CT scan is best
Pathophysiology
Pain
Pulmonary Contusion
Flail Chest
↓Chest Wall
Compliance
Inefficient Ventilation
EAST Guidelines
• Level 1
• Justifiable
• Class I data or strong Class II evidence
• Level 2
• Reasonably justifiable
• Class II or III evidence and strongly supported by expert opinion
• Level 3
• Supported by available data but adequate scientific evidence is lacking
• Class III evidence
Simon B, Ebert J, Bokhari F, Capella J, Emhoff T,
Hayward T III, Rodriguez A, Smith L. Practice
management guideline for "pulmonary contusion - flail
chest". Charleston (SC): Eastern Association for the
Surgery of Trauma (EAST); 2006 Jun. 74 p.
Level 1
• None
Level 2
• Should not restrict fluids
• Resuscitate as necessary
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Obligatory ventilation should be avoided
Optimize analgesia & chest physiotherapy
Epidural catheter is the preferred mode
Steroids should not be used
Level 3
• Consider CPAP
• Alert, compliant patients
• Consider independent lung ventilation may
be considered
• Surgical fixation may be considered in
severe unilateral flail chest or in patients
requiring mechanical ventilation when
thoracotomy is otherwise required.
Management Flail Chest
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A, B, C
Immediately life threatening injuries
No sandbags, towel clips
No corsets, bandages
Don’t probe chest wounds
Intubate if needed
Analgesia
Thoracic Epidural
Ullman DA Et Al. Reg Anesth 1989; 14(1):43
RCT n=28
%
Objectives of Surgery
• Stabilize chest wall
• Reduce ventilator time
• Avoid ventilator complications
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pneumothorax
pneumonia
empyema
ARDS
reduce late restriction
Thoracic Orthopedics
Case
• 85 year old belted
female passenger
MVC
• T-boned on
passenger side by
transport truck
• Intubated
• Multiple rib fractures
with flail segment
Outcome
• Discharged home 1 month post trauma
• Home shared with husband for 60 years
• CCAC
• Private “TLC” services from insurance
• 6 months later
• Completely independent
• Drives, plays bridge, bingo, groceries
• Volunteers in Senior’s Home
RCT of Flail Chest
Tanaka H et al. J Trauma 2002; 52(4): 727
• 37 patients in Tokyo, Japan
• All ventilated, epidural, bronchoscopy
• 5 days post injury Judet struts or internal
pneumatic stabilization
• ISS: 33 and 30
• Age: 43 and 46
• Fractures: 8 and 8
Results
Tanaka H et al. J Trauma 2002; 52(4): 727
12 Month Results
Tanaka H et al. J Trauma 2002; 52(4): 727
Who do I Fix?
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> 4 segment flail
Intubated
“Stove in” chest
Thoracotomy for other
indications
• Don’t:
• Severe head injury
• Other life threatening
injuries
Chest Trauma in the Elderly
• Less compliant lung
• Less pulmonary
reserve
• Weaker muscles of
respiration
• Chest wall more rigid
and brittle
• Osteoporosis
Increased Disability with Age
Albaugh G et al. Am Surg 2000
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58 flail chests
1994 - 1998 New Jersey
32 > 55 years vs. 26 < 55 years
132 % ↑ death / 10 years
30 % ↑ death / ISS
86% mortality if age > 80 years
Elderly do poorly
Confounders
• Medications
• Anticoagulants
• Coumadin
• ASA
• NSAIDs
• Cardiac medications
• β blockers
• Calcium channel
blockers
Case
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85 female
Fall down 8 steps
Chest pain
Crepitus
Ribs 2 to 12 with
flail
Injuries
• 11 ribs fractures and flail
• What service do you admit to???
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Medicine
ACE
Thoracic
Trauma
General Surgery
Orthopedics
Injuries
• 11 ribs fractures and flail
• What service do you admit to???
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Medicine
ACE
Thoracic
Trauma
General Surgery
Orthopedics
When to Refer
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Young
Old
Flail
Poor pain control
Rule out deep injuries
What’s New...?
VATS
• Evacuation of clotted
hemothorax
• Rule out diaphragmatic
rupture
• Repair pulmonary
lacerations
• Drain empyemas
• Repair rib fractures
Case
• 25 year female
• PMHx:
• Depression
• Previous suicide attempt
• Run over by train
Injuries
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C7 spinous process frature
T12 vertebral body compression
Left lung contusion
Right pubic rami fracture
Left scapular fracture
Left hemopneumothorax
Left buttock laceration
Left rib fractures 2 to 9 with flail 2 to 4
Bone Glue
Klin Khir. 1974 Nov;(11):15-29.Links
[Certain problems of pathophysiology of multiple rib
fractures and possibilities of osteosynthesis with
the use of cyanoacrylic glue (experimental study)]
[Article in Russian]
Vagner EA, Firsov VD, Starodubtsev NG, Poliakova AM, Sandakov PIa.
RibsTake Home
• Rib fractures
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are very common
Think about the inside
Marker for more serious injuries
Life threatening in elderly
Rare in infants – think abuse
Surgical fixation is promising
Pain control
Pain control
Question 5
• Where in London are the most ribs?
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Thoracic OR
Vascular OR
Tony Roma’s
London Rib Fest
Question 5
• Where are the most ribs in London?
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Thoracic OR
Vascular OR
Tony Roma’s
London Rib Fest
CHEST
is
BEST
™