Surgical plate fixation of multiple rib fractures

Case Studies 5 min 345

Font Size

Created On: 05/02/2020

Surgical plate fixation of multiple rib fractures

A 41-year-old Albanian man presented to the emergency department of the hospital had chest deformity, tachycardia, severe upper thoracic pain, hematoma, subcutaneous emphysema and dyspnea. Five days back, the patient had a road accident. Chest radiography detected a slight pleural effusion and hypoventilated lung fields. Hyperdensity regions from bone fragments, pulmonary contusion and displaced fractures of right lateral ribs 5-11 were observed in the CT scans. The appropriate treatment was given, and significant improvement in the patient’s clinical condition was noted. The patient was returned to his daily life schedule after six weeks.

What will be the most effective treatment for multiple rib fractures?

Small notch titanium reconstruction plates
DePuy Synthes MatrixRIB Fixation System

The blunt thoracic injuries caused during road accidents may result in the fracture of one or more ribs. Rib fractures constitute almost 20– 40% of trauma cases in the emergency departments, persuading numerous researchers to evaluate the best practice guidelines. Rib fracture management has come a long way from the conservative treatments based on external stabilisation, analgesia, and respiratory support to the internal surgical rib fixation. The recent evidence point towards the added clinical benefit of surgical fixation along with a multidisciplinary bundled care in patients with six or more rib fractures. In the present case, highly proficient team of trauma surgeons, physiotherapists, anesthesiologists and intensivists were utilized for advanced treatment.

See All

Key take away

Patient with multiple rib fractures showed significant improvement after surgical fixation of ribs 7–10 using titanium reconstruction plates and cortical locking screws.

Medical history

The patient reported no history of narcotic addiction. His family reported his habit of smoking and alcohol consumption on a regular basis.

Examination & lab investigations

On careful physical examination, chest deformity, hematoma, elevated blood pressure of 150/90 mmHg, subcutaneous emphysema and mild tachycardia (95–105 beats/min) was observed. The pain score of 5 was found on the visual analogue scale (VAS).

Laboratory evaluations: Laboratory evaluations revealed increased alanine aminotransferase (ALT)- 122 U/L and aspartate aminotransferase (AST)- 89 U/L, which could indicate liver trauma. Renal function of the patient was found to be normal with urea level 6.9 mmol/L and creatinine level 64.4 μmol/L. Body temperature and WBC count of the patient was found to be normal. Neurological examination revealed no abnormal findings.

Chest radiography depicted a slight pleural effusion, hypoventilated lung areas and several fractures of right lateral ribs. Transthoracic echocardiography showed normal pathology. Hyperdensity regions from bone fragments, pulmonary contusion and displaced fractures of right lateral ribs 5-11 were observed in the CT scans.

Management

Anterolateral thoracotomy was performed on the patient using general endotracheal anaesthesia. The areas where transection was executed include area under the chest, top of the costal margins, through cauterisation of the serratus, intercostal and pectoralis muscles. Four displaced ribs (7th to 10th) were stabilized using the titanium reconstruction plates (3.5 mm X 8 mm) and cortical locking screws. The surgery was terminated by adopting the standard procedure, after thoracic drainage, 32 Fr. The patient was shifted to the ICU after the surgery, where he stayed for 48 hours. Patient did not experience any severe complication after surgery.

Rehabilitative physical therapy program was started based on the patient’s feedback of low VAS score (<2) which was achieved within the first 12 hours. Again on mobilization, there was a significant increase in pain. The patient was earlier not comfortable with epidural analgesia but was now ready to get it placed. Sustained infusion of bupivacaine (0.25%; 3–5 ml/h) was given to the patient with an epidural catheter placed between the 4th and 5th lumbar vertebrae. The VAS pain score dropped to 2 with the use of epidural analgesia.

After 48 hours following the surgery, the assessment of a patient’s respiratory function revealed a gradual recovery and no use of the respiratory support system at all. The correct placement of the plates was confirmed by the chest X-ray analysis on day 4. Significant relief in pain (VAS =1) was depicted in the postoperative pain analysis on day 5. Total hospitalisation lasted for six days. Follow up was made at 3, 6, 12 and 23 weeks and 11 months. The patient reported complete physical and mental recovery at follow-up. The patient resumed working after six weeks, and also quit smoking ever since.

Discussion

The tremendous increase in multiple rib fractures is significantly related to increased pulmonary mortality and morbidity. Patients with six or more rib fractures are at higher risk of death due to reasons other than rib fractures. There is a need for an ideal clinical approach as per the severity of the rib fractures. These days, surgical fixation can be considered as an optimal treatment option for multiple rib fractures due to its considerable efficacy in providing better pulmonary function after surgery, a higher quality of life and quicker mobilization and verticalization.

In the present case, reconstruction plates were used to treat the rib fractures. Small notch titanium reconstruction plates were preferred due to their considerable versatility, cost-benefit and applicability to a broader patient population. Individuals with fractures of the radius, ulna, fibula, acetabulum, and metatarsals and cervical spine can be effectively treated with these titanium plates.

Learning

Surgical fixation of ribs using titanium reconstruction plates and cortical locking screws represents an effective treatment therapy to stabilize patient’s ribs and improve his overall condition.

References

Nicks B, Spasov M, Watkins C. The state and future of emergency medicine in Macedonia. World J Emerg Med. 2016;7(4):245–9.

Milevska Kostova N, Chichevalieva S, Ponce NA, van Ginneken E, Winkelmann J. The former Yugoslav Republic of Macedonia: health system review. Health Syst Transit. 2017;19(3):1–160.

Road Safety Status in the former Yugoslav Republic of Macedonia. http:// www.who.int/violence_injury_prevention/road_safety_status/2015/country_ profiles/The_Former_Yugoslav_Republic_of_Macedonia.pdf?ua=1. Accessed 12 Jan 2017.

de Moya M, Nirula R, Biffl W. Rib fixation: Who, What, When? Trauma Surgery & Acute Care Open. 2017;2(1).

Pieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, French B, Gasparri M, Marasco S, Minshall C, et al. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury. 2017;48(2):307–21.

Witt CE, Bulger EM. Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol. Trauma Surgery & Acute Care Open. 2017;2(1).

Platz JJ, Fabricant L, Norotsky M. Thoracic trauma: injuries, evaluation, and treatment. Surg Clin North Am. 2017;97(4):783–99. 8.

Caragounis EC, Fagevik Olsen M, Pazooki D, Granhed H. Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study. World J Emerg Surg. 2016;11:27.

Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg. 2013;216(2):302

Dupas P. Health behavior in developing countries. Ann Rev Econ. 2011;3(1): 425–49.

Han W. Health care system reforms in developing countries. J Public Health Res. 2012;1(3):199–207.

Nordyke RJ, Peabody JW. Market reforms and public incentives: finding a balance in the Republic of Macedonia. Soc Sci Med (1982). 2002;54(6):939 –53.

Durnez G. De engel op het eiland: 99 cursiefjes. Antwerp: Manteau; 1983.

Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76(2):462 –8.

Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, Gamelli RL. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005; 138(4):717 –23. discussion 723-725

Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52(4):727 –32. discussion 732

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(6):583 –7.