Page 34 - Delaware Medical Journal - November/December 2020
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Extensive Rib Plating in a Trauma Patient: A Case Report
Ryan C. Banning, MD; Brian T. Nam, MD
(p<0.05). A decreased rate of pneumonia, 24% versus 77% (p<0.05), was also found for 4
Similarly, a second study of 46 patients showed a decreased ICU length of stay, with group vs. 359 days in the non-operative group (p=0.03). There was also a decreased need for tracheostomy: 39% for those undergoing surgical stabilization of rib fractures compared to 70% for those treated with positive-pressure ventilation alone (p=0.04).5
A decreased ICU stay was also demonstrated in a third study of 40 patients which showed an average of 9.6 days versus 14.6 days in the non-operative group (p<0.001).6
With this background information in
mind, we present a case below of a patient who suffered blunt trauma and presented
to a Level I trauma center with multiple
rib fractures. The patient subsequently
CASE PRESENTATION
presented to our Level I trauma center
after being struck by a motor vehicle while walking along the side of the road. Notable decreased breath sounds on the left side
of the chest, a small and sluggish right fracture at the level of the right ankle.
The secondary survey revealed chest wall crepitus on the left side as well, and a chest X-ray obtained in the trauma bay showed
a left-sided pneumothorax with associated subcutaneous air. Due to pain and agitation, the patient was intubated, at which point the trauma activation was upgraded to
a code. A left-sided tube thoracostomy
was performed and the 28-French chest tube placed to suction. The patient was in stable condition and taken for computed tomography (CT) scans, with CT of the
INTRODUCTION
Rib fractures are a common injury among hospitalized trauma patients, occurring in
up to 20% of patients with blunt thoracic trauma.1 In addition to being common, these fractures are also associated with other traumatic injuries such as lung contusion, hemothorax, pneumothorax, and blunt cardiac injury. Morbidity and mortality can reach 10% for patients with one or more rib fractures, and are higher in the elderly.2 Rib fractures are generally treated conservatively, with a focus on aggressive pain control
that includes patient-controlled anesthesia (PCA) devices and epidural analgesia with infusion of opioids and/or local anesthetics. Pain management is combined with vigorous pulmonary toilette, including usage of an incentive spirometer, early mobilization, and chest physiotherapy.
Conservative therapy, however, may fail
in certain groups of patients. One clear indication for surgical intervention is the chest occurs when three or more adjacent ribs are each fractured in at least two places.3
This causes a lack of movement within the
spontaneous breathing. These patients usually manifest with tachycardia and tachypnea, and as a result of their injury have a decreased resting tidal volume due
to severe pain and underlying pulmonary contusion. In one study, shock was present in 41.2%, pulmonary contusion in 55.9%, and ventilator support is needed in up to 70% of patients.
The interest in open reduction and internal
waxed and waned in the thoracic surgery community over time as positive-pressure ventilation technology improved and became the mainstay of conservative management. Three randomized trials have been conducted inclusion criteria and similar results.
A randomized study of 37 consecutive patients demonstrated a decreased ICU length of stay, with an average of 16.5 days versus 26.8 days +/- 13.2 days, for those undergoing internal pneumatic stabilization
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Del Med J | November/December 2020 | Vol. 92 | No. 6
