Pre-Hospital • 54 y/o male with no past medical history fell off a 6ft ladder onto his right side • Presented to OSH complaining of right clavicular and chest pain • Found to have a comminuted right clavicular fracture, right-sided pneumothorax, and 3 right sided rib fractures Presentation to DUMC • Arrived as a level 2 trauma • Vital signs stable, O2 sat 96% on room air • Exam showed a patient in no acute distress with tenderness over right chest wall and clavicle • Primary, secondary, and tertiary surveys did not reveal other injuries Hospital Day 0-1 • Pigtail placed in the trauma bay • RUE made non-weight bearing and put in sling • Refused epidural due to good pain control with dPCA and oxy prn • Able to use IS to 1300cc Hospital Day 2 • Pigtail removed • dPCA removed and pain wellcontrolled on oral medications • Able to use IS to >1500cc • Discharged home with orthopedic follow-up for clavicle fracture Rib Fractures in Trauma • Most common injury in blunt chest trauma • Overall mortality rate between 10-22% Holcomb, et al., 2004 Rib fractures cause morbidity and mortality via three mechanisms: • Pain • Damage to the underlying lung • Altered breathing mechanics Flail Chest • Most severe form of chest trauma • Can be hidden in intubated patients • Mortality of 15-25% Wilcox, et al., 2013 Location Matters https://longuetraine.fr/index.php?article1312/anatomie-humain Disposition • Some patients with rib fractures may be discharged home from the emergency department • Low admission threshold for: • • • • Age >65 or younger patients with underlying disease >3 rib fractures Any signs of respiratory compromise Inadequate pain control https://www.uptodate.com/contents/image?imageKey=EM%2F117179&topicKey=EM%2F246&search=rib%20fracture&rank=1~111&source=see_link Non-Operative Management • Pain control • Non-opiates are effective • Pulmonary toilet • Regional anesthesia Contraindications to loco-regional anesthesia Absolute contraindications Relative contraindications Hypovolemia Spinal Trauma Elevated ICP Coagulopathy Infection at catheter site Thrombocytopenia <100K Allergy to anesthetic Unreliable neuro exam Patient refusal Abnormal anatomy Brasel, et al. 2016 Surgical Management • Goal: reduce pain and normalize pulmonary mechanics • Early surgery is preferred • Potential candidates: • Flail chest • ≥3 displaced fractures • 24 hours of failed maximal medical therapy Battle, et al., 2013 Surgical Outcomes • Complications: • Short term: • • • • Pneumonia Tension Pneumothorax ARDS Implant infection • Long term: • Implant irritation • Plating system failure • Limited data showing good long term outcomes after fixation References • Battle, C., Hutchings, H., Evans, P. Blunt chest wall trauma: A review. Trauma. 15.10.1177, 2013. • Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48:1040–7. • Holzmacher, J, Sarani, B. Surgical Stabilization of Rib Fractures. Curr Surg Rep 2017;5:22 • Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alar-con L, et al. Operative fixation of rib fractures after blunt trauma:a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82:618–26. • Majercik S, Cannon Q, Granger SR, VanBoerum DH, White TW, Van Boerum DH, et al. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg. 2014;208:88–92. • Moore, SM, Pieracci, FM, Jurkovich, GJ. Chest Wall, Pneumothorax, and Hemothorax in Current Surgical Therapy, 1151-1158. Elsevier Inc. 2017. • Wilcox, SR, Bittner, EA, Flail Chest and Pulmonary Contusion in Critical Care Secrets (Fifth Edition), Elsevier Inc, 2013. Questions?