Fixing Rib Fractures

Did you ever break a rib? 

As trauma nurses, first we look for signs that the rib punctured a lung - which would lead to a pneumothorax. Difficulty breathing after a rib injury may mean that your lung has collapsed and you need a chest tube.

However, difficulty breathing after a rib injury may be just because it hurts like Hell every time you breathe. Our intercostal muscles expand and contract our rib cage every time we inhale or exhale. 

Rib pain leads to shallow breathing. Shallow breathing leads to lung collapse or fluid accumulating in the lower lobes of the lungs, and that leads to pneumonia and other complications. 

We recently had a rib fracture specialist from Dr.John Mayberry Oregon Health Science University come and talk to the staff at our hospital. 

Here are a few of the takeaways:

• It is going to hurt - expect the pain to last for 3 to 4 months and it will take at least 50 days to get back to normal activity. 
• Toradol can help in the initial phase and Lidocaine patches can work too. 
• Incentive Spirometer, Cough and Deep Breathe ... but you already knew that. Respiratory, PT and OT is important to avoid complications. Get them out of bed and keep 'em moving. 
• Physiologic reserve - this drops after the age of 65 and means that you should admit patients with three or more rib fractures. Older than 65 and more than 6 fractured ribs is associated with a higher morbidity and mortality. Of course, with that mechanism, there is also the likelihood of multiple injuries.   

Why don't we internally fixate rib fractures like other broken bones? Mayberry is leading a study group on surgical and outpatient management of rib fractures. According to the OHSU website:

“Historically, physicians have been taught that nothing can be done to fix a rib fracture,” said John Mayberry, M.D., principal investigator of the study and associate professor of surgery in the OHSU School of Medicine. “My colleagues and I have long thought that wasn’t true, but we have yet to prove it. With this study, we hope to identify subsets of people who respond better to surgical repair than nonsurgical therapy, then develop a standard criteria for treatment.” 

Like clavicle fractures, rib fractures are one of those traumatic injuries we've always assumed healed best when left alone. We give patients tons of narcotics and tell them to cough and deep breathe. It takes a long time for these method to work.

  “Based on findings from our previous research, we are convinced that current, traditional nonsurgical management of rib fractures does not facilitate pain relief or a speedy return to normal activity. We believe new strategies, including a minimally invasive surgical method we’ve developed, will alleviate pain and reduce disability for individual participants,” said Mayberry, adding that patients in the United States disabled by acute rib fractures collectively lose approximately 58,000 years of productive work each year.

Damage Control - Keep Them From Sinking

When it comes to major trauma, often the role of the trauma team is Damage Control.

We are not attempting to fix all the problems a patient has at the time of presentation -- we may not even have time to identify all the damage suffered -- our primary goal is to stabilize the patient to allow for difinative treatment down the road.

"The concept of Damage Control came from the Navy," explained Dr. John Mayberry. "The idea was to keep a ship in combat from sinking, not to try and make all the repairs needed, just to try and get out of open water and get to port." Once safe at port, full repairs can be initiated.

This concept has long applied to trauma as well. Our job is to get the patient out of open water (the emergency department) and into port (the ICU) without sinking.

At last week's Northwest States Trauma Conference, two different approaches to damage control were presented. Mayberry - a professor of surgery at Oregon Health Science University - looked at 30 years of applying the damage control model to open abdominal wounds.  When a patient comes complex abdominal injuries and blood loss, they are often not stable enough to withstand the additional stresses of a long surgical proceedure to address every point of injury.

"Instead of definitive repair of multiple intra-abdominal injuries, the focus of damage control laparotomy is rapid control of hemorrhage, restitution of vital organ blood flow with temporary shunts, and closure of hollow viscus lacerations without anastomosis."

If major bleeding is the overriding problem, skin or fascia is closed tightly to produce tamponade. However, when tamponade  of bleeding is not vital, the belly is left open and and a Temporary Abdominal Closure (TAC) is used. As the patient is stabilized a series of operations are performed to repair injuries and remove packing, slowly closing the abdomen while attempting to avoid Intra-Abdominal Hypertension, he explained.

Temporary closure -- whether it be with a the good old Bogata Bag or the increasingly popular vacuum packs -- seems to yield good outcomes as far as recovery from injury and eventual return to work.

Measuring Intra-Abdominal pressures has been found to be beneficial to patients, increasing survival from 50 % to 72 % in one study while actually decreasing resource utilization.

Overall Mayberry's review concluded that the Damage Control approach to abdominal surgery is well worth it. Aggressive management of intra-abdominal hypertension and decompression is beneficial. Early progression to fascial closure prevents complications and long term outcomes are usually good.