Surgical plate fixation of multiple rib fractures

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Surgical plate fixation of multiple rib fractures

A 41-year-old Albanian man was admitted to the emergency department following a pedestrian-vehicle accident five days earlier. He had severe upper thoracic pain, chest deformity, dyspnea, tachycardia, subcutaneous emphysema, and hematoma. Hypoventilated lung fields and minor pleural effusion was detected in the chest radiography. As per the computed tomographic scans, there were displaced fractures of right lateral ribs 5 –11, hyperdensity regions from bone fragments, and pulmonary contusion. The treatment comprised of surgical fixation of ribs 7–10 using titanium reconstruction plates and cortical locking screws. The patient’s clinical condition improved postoperatively. After six weeks follow-up, a full return to preoperative daily activities and high quality of life was confirmed.

What will be most helpful in the treatment of multiple rib fractures?

  • Small notch titanium reconstruction plates
  • Precontoured locking plates of the MatrixRIB™ Fixation System (DePuy Synthes)

 

Introduction

The developing countries face issues in maintaining the pace of the public healthcare system due to lack of expert medical staff, inadequate medical infrastructure and restricted financial aids. One such country- the Republic of Macedonia, have limited emergency and trauma medicine. As a result, the trauma injuries poses as a significant source of morbidity and mortality, than the other Western countries. Regardless, private healthcare practitioners support the public system and play a significant part in the advancement of clinical practice in developing countries.
During road accidents, the blunt thoracic injuries frequently 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. But, several lines of evidence point towards that surgical fixation complemented with a multidisciplinary bundled care pathway provides superior clinical benefit, especially for patients who have sustained six or more rib fractures.
This case report entails an advanced multidisciplinary treatment supported by a highly skilled team of anesthesiologists, trauma surgeons, intensivists, and physiotherapists. This report denotes an imperative advancement in emergency and trauma medicine in the Republic of Macedonia.

 

Medical History

The patient had no history of narcotic addiction, but the patient’s family reported that he is a regular smoker. He consumes above average amounts of alcohol as well.

 

Examination and Laboratory Investigations

The examinations disclosed an elevated blood pressure of 150/90 mmHg, mild tachycardia (95–105 beats/min), a chest deformity, subcutaneous emphysema and hematoma. The visual analogue scale (VAS) for pain has a score of 5. Thereon, the patient’s pain intensity was noted every 60 minutes; pain management was performed using intravenous analgesics as the patient was uncooperative with the epidural anaesthesia.
Laboratory evaluations: These evaluations implied to possible liver trauma, depicted by surged aspartate aminotransferase (AST)- 89 U/L and alanine aminotransferase (ALT)- 122 U/L, which was not included by computed tomography (CT). The patient had a normal renal function, Urea and Creatinine levels of 6.9 mmol/L and 64.4 μmol/L. The patient had a normal body temperature (36.6 °C) and white blood cell counts (8.8*103 cells/μl). There were no neurological abnormalities.
The results of chest radiography depicted possible fractures of several right lateral ribs, hypoventilated lung fields, and minor pleural effusion. Transthoracic echocardiography revealed no other abnormalities. The patient had steady hemodynamics as his left ventricular ejection fraction was 60% and blood pressure was 120/80 mmHg. Computed tomographic scans revealed displaced fractures of right lateral ribs 5–11, hyperdensity zones from bone fragments, and pulmonary contusion.

 

Management

General endotracheal anaesthesia was used followed by an anterolateral thoracotomy. The transection was executed below the chest, above the costal margins, through cauterisation of the pectoralis, serratus, and intercostal muscles. The titanium reconstruction plates and cortical locking screws (small notch titanium reconstruction plates with a thickness of 3.5 mm and width of 8 mm was used to stabilise four displaced ribs, the seventh through tenth. Following thoracic drainage, 32 Fr, the surgery was ceased via standard closure of the intercostal wound incision and suturing overlying tissue. The patient was shifted to the ICU after the surgery, where he stayed for 48 hours. There were no serious postoperative complications.
Within the first 12 hours, the patient described a low VAS pain score (< 2) and so, a rehabilitative physical therapy program was initiated. But, the patient encountered significant pain (VAS score of “6 – 8”) upon mobilisation. He then allowed the placement of an epidural catheter between the 4th and 5th lumbar vertebrae for sustained infusion of bupivacaine (0.25%; 3–5 ml/h). Epidural analgesia helped decline the patient’s VAS pain score to 2.
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. On day 4, control chest X-ray analysis confirmed the correct placement of the plates. On day 5, postoperative pain analysis indicated a substantial relief from pain discomfort (VAS pain score of 1. Total hospitalisation lasted for six days. A 3, 6, 12, and 23 weeks and 11 months follow-up using the outpatient clinic visits and phone contact, depicted a complete physical and mental recovery with no residual symptoms. The patient resumed working after six weeks, and he quit smoking ever since.

 

Discussion

This case report presents a novel and significant development in emergency medicine in the Republic of Macedonia. Multiple rib fractures due to blunt thoracic trauma are mostly treated through conservative means for socioeconomic reasons and due to limited health insurance coverage. Developing countries face issues to keep pace with the ever-evolving medical technology and practice guidelines. In the Republic of Macedonia, market reforms and public incentives have been in place to improve the efficiency and standard of primary health care ever since the fall of former Yugoslavia. But, the emergency and trauma medicine is still poorly established despite these measures. Shared efforts and infrastructure across public and private sectors can cater to develop advanced clinical practice and innovation in medical science.
The growing numbers of multiple rib fractures correspond with pulmonary morbidity and mortality. The patients who experience fractures of six or more ribs are at significant risk for death due to causes (un)related to the rib fractures. There is a need for an ideal clinical approach as per the severity of the rib fractures. Currently, Surgical fixation is the bedrock of treatment for multiple rib fractures as it offers better postoperative pulmonary function, quicker verticalization and mobilisation, and a higher QoL.
In this case, the rib fractures were treated via reconstruction plates rather than the pre-contoured locking plates of the MatrixRIB™ Fixation System (DePuy Synthes). To maintain the cost-effectiveness and applicability to a broader patient population, small notch titanium reconstruction plates were preferred due to their versatility. Other than rib fractures, these plates can be applied to treat several fracture types, for example, fractures of the radius, ulna, fibula, acetabulum, and metatarsals and certain cervical spine fracture.

 

Learning

Surgical plate fixation via small notch titanium reconstruction plates efficiently stabilise the patient’s ribs, alleviate his symptoms, rapidly improves his clinical condition, and encourage a swift reintegration into society. This report focuses on a novel and promising medical advancement in the Republic of Macedonia and Southeast Europe. Despite the stagnating progress of emergency medicine and limited national healthcare systems, trauma injuries can be treated successfully as per the current international medical guidelines for most optimal recovery possible.

 

References

  1. Nicks B, Spasov M, Watkins C. The state and future of emergency medicine in Macedonia. World J Emerg Med. 2016;7(4):245–9.
  2. 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.
  3. 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.
  4. de Moya M, Nirula R, Biffl W. Rib fixation: Who, What, When? Trauma Surgery & Acute Care Open. 2017;2(1).
  5. 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.
  6. 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).
  7. Platz JJ, Fabricant L, Norotsky M. Thoracic trauma: injuries, evaluation, and treatment. Surg Clin North Am. 2017;97(4):783–99. 8.
  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.
  9. 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
  10. Dupas P. Health behavior in developing countries. Ann Rev Econ. 2011;3(1): 425–49.
  11. Han W. Health care system reforms in developing countries. J Public Health Res. 2012;1(3):199–207.
  12. 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.
  13. Durnez G. De engel op het eiland: 99 cursiefjes. Antwerp: Manteau; 1983.
  14. 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.
  15. 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
  16. 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
  17. 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.
Exploratory, Pain, Fracture, Ribs, Upper thoracic, Chest, Case report
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