Rib Fractures
In recent years, there has been an increasing interest in the treatment of rib fractures. The epidemiology and the outcome in the treatment of Traumatic rib fractures have been studied and more and more it has been noted that data are inconsistent and outdated among patients. There is definitively insufficient reporting as well as insufficient outcome, a definitive marker for severe injury.

We remember well the way a “flail chest” used to be managed with a towel clip attached to the flail segment of ribs and a traction apparatus hooked to the ceiling, providing an expansion of the thoracic cage. By this way, the traumatized lung was allowed to expand and heal from the injury over time. It is a way for me to review most of our trauma scores for the lector of our AMHE Newsletter can be at ease and understand better why we adopted such decision-making tools.

Since Trauma Scores have been used to guide the traumatologist in a systematic approach. Nowadays trauma management rest on a complex tree of decisions from the on-scene resuscitation and the rescue ambulance team to the evaluation in the Emergency room, where diagnostic tests are performed to asset a diagnosis or take the decision for a trip to the operating room where clinician-specialists will secure the best chances of survival for the patients.

Current literature on trauma scores so far have shown that anatomical trauma scores (ISS=Injury Severity Score and NISS=New Injury Severity Score) have better predicted intensive care unit (ICU)) admission while physiological trauma scores (RTS) have shown a better prediction for the mortality and Trauma Injury Severity Score (anatomo-physiological) has predicted better ICU hospitalization length of stay and better mechanical ventilation time. NISS was superior to ISS in predicting mortality and complications in penetrating trauma patients.

These trauma scoring systems have played an important role in the management of the polytraumatized patients. In the 1970’s, GCS (Glasgow Coma Scale) and ISS and later in the 1980’s RTS and TRISS (Trauma Injury Severity Score) have improved the management of the victims.in predicting mortality by allowing to perform retrospective chart reviews of patients treated in a Level 1 trauma.

The high morbidity rate following chest wall injuries and the fact that incisions used for thoracotomies have prevented trauma surgeons from performing operative treatment on ribs fractures. Many are thinking in approaching the thoracic cage via smaller incisions to provide better stabilization of the ribs. Then, the treatment of a flail chest has changed considerably in the past decade. The focus has shifted away from the fracture component to the underlying lung contusion with adequate analgesia, pulmonary hygiene, minimal fluid management and selective intubation. Recently the benefit in surgical rib stabilization was demonstrated, improving mortality and decreasing the length of stay and accelerating the recovery.

A retrospective review has reported that a percentage of 4.36% of patient with a flail chest were surgically treated. Smaller muscle sparing incisions were used to stabilize the ribs with smaller hardware and less screw fixation. The use of intra vs extra thoracic plates fixation or intramedullary splints are being investigated in many trauma centers around the world.

The current literature on the epidemiology and outcomes of rib fractures is outdated and appear to be inconsistent. Especially because of insufficient literature reporting on different subgroups. The National Trauma Data Bank was used to review rib fractures and flail chest treated between January 2010 and December 2016 and classified by the International Classification of Diseases based on the 9th Revision diagnostic codes. Almost 565.000 patients with one or more rib fractures were reviewed:45% were with polytrauma with 2% with open rib fractures and 4% with flail chest due to MVA. Blunt chest injuries accounted for 95% of rib fractures. An overall mortality rate was 5.6% where half polytraumatized patients with flail chest presented the worse outcomes. Penetrating chest injuries accounted for 2.9% of the injuries

Frequently, thoracic trauma is seen in almost 15% of all trauma-related admissions and represent 35% of all trauma-related deaths in the USA after cardiovascular injuries and traumatic brain injury. A rib fracture is most common seen in a chest trauma, often caused by a high impact force to the chest wall. The rib fractures may be associated with significant pulmonary morbidity and mortality and can also certainly affect the quality of life. The fractures can be isolated or as part of extensive thoracic injuries or associated with concomitant injuries to the head, abdomen or extremities.

The number of rib fractures has been debated and it was found that there was a direct correlation between the number of ribs fractures and the mortality and morbidity. Other studies discussed also age and multiple systems involvement as predictor for morbidity and mortality. An age of 65 associated to three or more rib fractures or the presence of pre-existing co-morbidities like cardiopulmonary disease is certainly a risk factor.to develop further complications. More the development of pneumonia post injury brings also a significant risk factor.

Up to 25% of patients with traumatic rib fractures in our sample study can be placed in an unadjusted mortality rate where the highest mortality rate obtained was observed in the Flail Chest (13%) followed by polytrauma (10.6% and elderly persons (7.6%). In this study also the penetrating injuries showed an increase in the mortality rate. Other studies have also reported risk factors associated with mortality in patients with rib fractures after blunt trauma although age, male gender, ISS, GCS scores as well as pre-existing mortalities, numbers of ribs fractures with concomitant sternum facture were found to be associated to a higher risk of mortality. Open fractures, hemothorax have also contributed to the problems. Strangely a phenomenon of “smoker’s paradox” may be seen when smoking is seen as beneficial in reducing morbidity and mortality in severely injured patients. Such paradox is also seen in patients with cardiovascular disease. The clinical implication is not well understood.

Rib fractures are the most common traumatic injury and up to 25% of all patient suffering from a thoracic injury may well suffer from a rib fracture. As we have seen, the majority of such fracture are seen in blunt injuries and the hallmark of such a rib fracture is pain. Lung contusion is almost always seen as well. Such fracture carries with it an increased morbidity and mortality especially when dealing with a flail chest.in an elderly population. Let us be sure we define the term although we have used it before. A “Flail chest” is defined radiologically as 3 or more consecutive ribs fractures in two or more places. Often, the flail is associated with a paradoxical chest wall movement during respiratory cycles, creating pain and difficulty in breathing. The need for a pain control and respiratory support with positive pressure ventilation has always been the mean of treating such fractures.

The past twenty years has shown evidence to suggest that open reduction and internal fixation of the ribs can bring benefits to the patient suffering with such injury. What are the indications for such procedure…?  As discussed above, studies have shown how the most severely injured patient with flail chest or with chronic non-unions can benefit from such procedure.

Physicians in the ancient Egypt have shown interest in the surgical treatment of rib fractures and documents found as far as Edwin Papyrus time, have related in 1600 CE on surgical treatment to rib fractures. 48 cases were described in these ancient texts in relation to chest trauma and rib fractures. Chest injury remains an important source of loss of work days and can affect a patient for months following the injury especially if associated lung contusion, hemothorax, pneumothorax or blunt cardiac injury is associated. Multiple rib fractures and flail chest have also a higher mortality and respiratory failure. Often, the underlying contused lung is responsible for the respiratory failure and a source of pain. Therefore, the improvement of the respiratory machine and the pain control remain an essential strategy in the rehabilitation of such patients.

The 1950’s have seen an effort to impose open reduction and internal fixation in the treatment of multiple ribs fractures. In Paris, during the 1975’s, a study demonstrated the benefit of internal fixation as a primary mean of fixation with “K” wires. Surgeons become more comfortable and started performing open reductions and internal fixation (ORIF). It was recommended that five or more rib fractures with a flail segment should be treated with plating especially if the condition requires invasive or non-invasive positive pressure ventilation. This can become necessary in patient with traumatic brain injury or quadriplegic with high cervical cord injury or severe lung disease. The use of pain severity was also used as a determinant for rib fixation. Other indications like symptomatic non-union, chest deformity etc were also considered as criteria for rib fixation.